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fi«  EOOSTOH  MSREITT;  M.  D. 


GENERAL  PARESIS 


CHASE 


GENERAL  PARESIS. 


GENERAL  PARESIS 


PRACTICAL  AND  CLINICAL 


ROBERT  ROWLAND  CHASE,  A.M.,  M.D. 

PHYSICIAN-IiSr-CHIEF,    FRIENDS    ASYLUM  FOR   THE    INSANE;     LATE    RESIDENT    PHYSI- 
CIAN, State  Hospital,  ISTorristown,  Pa.;   Member  of  the  American 
Medico-Psychological  Association  ;  Fellow  of  the 
College  of  Physicians,  Philadelphia. 


Illustrated 


PHILADELPHIA 

P.  BLAKISTON'S   SON   &    CO. 

IOI2  Walnut  Street 

1902 

BARTLETT 


Copyright,  1902, 
P.  Blakiston's  Son  &  Co. 


"Of  the  uncertainties  of  our  present  state,  the  most 
dreadful  and  alarming  is  the  uncertain  continuance  of 
REASON." — Dr.  Johnson's  Rasselas. 


PREFACE. 

In  an  experience  of  more  than  twenty-five  years 
among  cases  of  nervous  and  mental  diseases  the 
author  has  had  frequent  occasion  to  remark  the  lack 
of  knowledge,  among  general  practitioners,  of  the 
details  of  paresis. 

It  should  be  remembered  that  on  this  branch  oi 
the  profession  devolves  the  care  of  these  cases  at  the 
onset,  and  on  these  members,  as  the  family  physician, 
must  rest  the  responsible  decision  of  diagnosis  and 
early  treatment,  which,  in  so  many  ways,  may  mean 
much  or  little.  In  searching  for  the  cause  of  this 
limitation  of  knowledge  in  this  prevalent  disease,  he 
was  doubly  impressed  with  the  meagreness  of  the 
available  material  on  the  subject.  To  be  sure,  the 
current  literature  is  voluminous,  but  it  is  scattered, 
and  not  in  a  form  to  meet  the  needs  of  the  busy 
physician.  Hence,  the  writer  has  set  about  to  com- 
pile a  study  of  general  paresis  addressed  to  the  prac- 
titioner and  the  student  in  medicine  with  the  view  of 
laying  before  them,  as  clearly  as  he  may,  the  special 
features  of  this  wonderful  disease,  which  claims  its 
victims  from  every  walk  and  station  of  life. 

There  has  been  no  pretence  on  his  part  to  settle 
scientific  questions  that  are  still  in  dispute  by  investi- 
gators; neither  has  there  been  an  attempt  to  advance 
original  views  and  individual  opinions  beyond  giving 
the  practical  results  of  his  own  experience  and  re- 
search. In  gleaning  from  the  field  of  medical  writ- 
ings, purporting  thereto,  he  is  indebted  to  a  number 
of  friends,  whose  assistance  is  herewith  acknowl- 
edged. The  illustrations,  for  the  most  part,  have 
been  taken  from  the  very  ample  clinical  material  at 


Vlll  PREFACE. 

the  State  Hospital,  Norristown,  Pa.,  and  the  Insane 
Department  of  the  Philadelphia  Hospital,  together 
comprising  an  insane  population  of  nearly  four  thou- 
sand patients.  To  his  friends,  the  chief  medical  offi- 
cers of  these  institutions.  Dr.  D.  D.  Richardson  and 
Dr.  D.  E.  Hughes,  he  gladly  takes  this  opportunity  ot 
expressing  his  obligations  for  the  man}'  courtesies  re- 
ceived at  their  hands.  In  making  abstracts  from  the 
various  authorities,  he  trusts  that  a  too  liberal  version 
of  their  writings  has  not,  here  and  there,  crept  in — a 
fault  into  which  one  may  inadvertently  fall;  and  in 
quoting  from  them  that  due  credit  has  been  given. 

If,  then,  in  the  profession  at  large,  the  writer  be  so 
fortunate  as  to  awaken  a  further  interest  in  a  disease 
so  widespread  and  significant  as  general  paresis,  he 
will  feel  that  the  important  object  of  his  work  has 
been  attained. 

R.  H.  C. 

Philadelphia,  July,  1902. 


CONTENTS. 


CHx\PTER  I. 

IXTRODUCTORY,  .  .  .  .  .  •  .  •        ^7 

CHAPTER  II. 

Synonyms.      Definition.      Mode    of   Commencement. 

Stages, 22 

CHAPTER  III. 
Prodromal  Stage,  .......     27 

CHAPTER  IV. 

First  Stage  of  the  Established  Disease,    .         .         -41 

CHAPTER  V. 

Second  Stage  of  the  Established  Disease,  .         .     55 

CHAPTER  VI. 

Third  Stage  of  the  Established  Disease,  .         .         .64 

CHAPTER  VII. 

Varieties  of  General  Paresis.  Galloping,  Circu- 
lar, Melancholic,  and  Spinal  Forms,   .         .         -73 

CHAPTER  VIII. 

Varieties  {continued).  Simple  Progressive  Demen- 
tia, Juvenile  Form,  Paresis  in  Woman,  and 
Senile  Form,    ........     94 

CHAPTER  IX. 

Particular    Symptomatology.      Moral    Perversion. 

Sexual  Instinct.     Hallucinations,        .         .         .110 


X  CONTENTS. 

CHAPTER  X. 

Particular  Symptomatology  (^continued ) ,  Facial  Ex- 
pression. Speech.  Handwriting.  Gait.  Tre- 
mor.    Reflexes,      .         .         .         .         .         .         .116 

CHAPTER  XI. 

Particular  Symptomatology  {^conti?iued).     Cerebral 

Seizures.     Eye  Symptoms,       .         .         .         .         .127 

CHAPTER  XII. 

Particular  Symptomatology  {continued).  Sleep. 
Pain.  Headache.  Sensory  Disturbances.  Tro- 
phic Changes.     Bones.     Hematoma  Auris,    .         .   145 

CHAPTER  XIII. 

Particular     Symptomatology    (continued).      Blood. 

Temperature.     Pulse.     Bladder.     Urine,  .         .   164 

CHAPTER  XIV. 
Differential  Diagnosis,        .         .         .         .         .          .172 

CHAPTER  XV. 
Etiology,  ........   187 

CHAPTER  XVI. 

General  Paresis  following  Ordinary  Insanity,  Re- 
missions.    Duration.     Prognosis.      Termination.   224 

CHAPTER  XVII. 
Pathology  and  Pathological  Anatomy,       .  .  .   246 

CHAPTER  XVIII. 
Treatment,     .........  267 

Index,      ..........   283 


LIST  OF  ILLUSTRATIONS. 


Plate.  Facing  Page. 

Frontispiece.     A  Typical  Face  of  General  Paresis 
I.   Types  of  the  Prodromal  Stage     ....        28 
II.  Types  of  the  First  Stage  of  the  Established   Dis- 
ease        ........     42 

III.  Types  of  the  Second  Stage  of  the  Established  Dis- 

ease        ........      5^ 

IV.  Types  of   the  Third  Stage  of  the  Established  Dis- 

ease        ........     64 

V.   Types  of  the  Spinal  Forms  of  General  Paresis         .     88 

VI.   Type  of  the  Juvenile  Form  of  the  Disease      .  .     98 

VII.   Types  of  General  Paresis  in  Woman     .  .  .106 

VIII.   Specimens  of  the  Handwriting  in  General  Paresis    119 

IX.  Normal   Gait    Compared    with   the    Paretic    Gait 

(modification  of  Mills  after  Marie)  .  .  .121 

VIII  a.   Right  Iridoplegia  (Dilatation  of  Pupil)  in  Paresis 

(Mills) 138 

IX  b.   Spontaneous  Fractures  and  Arthropathic   Disinte- 
grations (Charcot  per  Church-Peterson)  .  -158 
X.   Types  of  General  Paresis  in  the  Negro            .  .210 
XL   General     Paresis    Supervening   upon    Epilepsy    in 

Woman  .  ,  .  .  .  .  .218 

XII.   Vertex  of  the  Brain  in  Advanced  General  Paresis 

(Clouston)       .......   248 

XIII.  Normal    Capillaries    of    the    Coitex    and    Normal 
Nerve-cells  Compared  with  those  in  Advanced 

General  Paresis  (Clouston  and  Ford  Robertson)    262 
Fig. 

1 .  Station     in     Tabetic    Form     of     General     Paresis 

(Church-Peterson)  .  .  .  .  -9^ 

2.  Arthropathy  of  Knee-joint  in  General  Paresis  (A. 

S.  Roberts  vide  Dana)     .  .  .  .  •    151 

3.  Hematoma  Auris  in  General  Paresis  (Williams)     .    162 

4.  Degeneration  of  Nerve-cells  in  Cortex  with  Prolif- 

eration   of     the    Spider    or    Scavenger-cells    in 
General  Paresis  (B.  Lewis)      ....   254 


GENERAL  PARESIS. 


CHAPTER   I. 


INTRODUCTORY. 


In  undertaking  the  study  of  this  mutable  malady, 
one  will  promptly  find  that  he  has  entered  upon  no 
easy  task,  if  his  object  be  to  gain  a  comprehensive 
view  of  it.  Let  this,  however,  be  no  discouragement 
to  the  earnest  student,  though  he  discover,  as  he  cer- 
tainly will,  that  many  of  the  authorities  differ  in  the 
interpretation  of  its  important  features  and  that  some 
there  are  who,  as  partisans  of  the  dual  theory^  of 
general  paresis,  deny  that  it  comprises  a  true  entity, 
distinct  in  symptoms  and  course. 

The  student  should  especially  keep  in  view  that  in 
this  disease  he  is  dealing  with  a  gradual  decay  of  the 
higher  nervous  tissues,  a  decay  which  destroys  the 
nerve  centers,  and  spreads  progressively  both  in 
breadth  and  depth. 

The  causes  may  differ  greatly;  but  whether  the 
disease  originates  from  premature  disease  of  the 
arteries,  from  over-strain  and  insufficient  nutrition, 
from  imperfect  rest  and  reproduction  of  nerve  tissue, 
or  from  the  changes  of  relations  between  brain  and 

'  M.  Delaje,  a  French  writer  in  the  early  part  of  the  last  century,  was 
the  first  one  to  advocate  its  duality,  and  since  then  there  have  been  many 
adherents  to  this  theory.  At  the  present  day  this  belief  is  held  by  a  num- 
ber of  prominent  authors.  Of  its  advocates,  Reginald  Farrar,  in  the  Jour- 
nal of  Mental  Science,  1895,  has  made  the  most  vigorous  attack  in  late 
years  upon  the  specific  unity  of  general  paresis. 

2  17 


15  INTRODUCTORY. 

vessels  resulting  from  injury  or  disease,  certain  facts 
concerning  its  development  are  without  contradic- 
tion: (i)  The  disease  is  invariably  progressive;  (2) 
its  action  upon  brain  or  cord  is  very  slight  in  the 
early  stage  and  difficult  to  detect;  (3)  it  rarely  affects 
a  large  part  of  the  brain  or  nervous  system  suddenly; 

(4)  it  affects  first  the  highest  intellectual  and  motor 
arrangements,  which  is  followed  necessarily  by  an 
impairment  of  the  associated  mental  phenomena;   and 

(5)  in  whatever  manner  the  symptoms  may  differ  in 
the  beginning,  depending  on  the  regions  of  the  cortex 
involved,  and  however  much  they  may  vary  in  mode 
of  onset,  progress  and  duration,  towards  the  end  of 
the   disease  they  are  markedly  similar  (Savage). 

The  date  of  the  discovery  of  general  paresis  is  not 
more  remote  than  eighty  years  ago;  and  to  French 
pathologists  indisputably  belongs  the  credit  of  having 
first  recognized  and  described  it  as  a  special  form  of 
disease.  There  are,  however,  passages  in  the  writ- 
ings of  Willis,  the  anatomist  (1670),  indicating  a 
knowledge  of  the  association  of  paralysis  and  insan- 
ity;   and   Haslam^  and   Perfect,  at  the   close   of  the 

'J.  A.,  a  man,  forty-two  years  of  age,  was  first  admitted  into  tiie  house 
on  June  27,  1795.  His  disease  came  on  suddenly  wliile  he  was  working  in 
a  garden,  on  a  very  hot  daj,  without  any  co\ering  to  liis  head.  He  had 
some  years  before  travelled  with  a  gentleman  over  a  great  part  of  Europe ; 
his  ideas  ran  particularly  on  what  he  had  seen  abroad ;  sometimes  he  con- 
ceived himself  the  king  of  Denmark,  at  other  times  the  king  of  France. 
Although  naturally  dull  and  wanting  common  education,  he  professed 
himself  a  master  of  all  the  dead  and  living  languages  ;  but  his  most  inti- 
mate acquaintance  was  with  the  old  French  ;  and  he  was  persuaded  he  had 
some  faint  recollection  of  coming  over  to  this  country  with  William  the 
Conqueror.  His  temper  was  verv  irritable,  and  he  was  disposed  to  quarrel 
with  everybody  about  him.  After  he  had  continued  ten  months  in  the 
hospital,  he  became  tranquil,  relinquished  his  absurdities,  and  was  dis- 
charged well  in  June,  1796.  He  went  into  the  country  with  his  wife  to 
settle  some  domestic  affairs,  and  in  about  six  weeks  afterwards  relapsed. 
He  was  re-admitted  into  the  hospital  August  13.  He  now  evidently  had  a 
paralvtic  affection  ;  his  speech  was  inarticulate,  and  his  mouth  drawn  aside. 
He  shortly  became  stupid,  his  legs  swelled,  and  afterwards  ulcerated;  at 
length  his  appetite  failed  him  ;  he  became  emaciated,  and  died  December 
27  of  the  same  year.     (Haslam  on  Madness,  London,  1809.) 


INTRODUCTORY.  1 9 

eighteenth  century,  reported  cases  having  a  combina- 
tion of  the  two  series  of  symptoms,  of  paralysis  and  de- 
mentia, but  both  of  them  failed  to  recognize,  as  did  Wil- 
lis, the  clinical  import  of  their  observations.  In  1815, 
Esquirol,  under  the  head  of  monomania  in  his  Mala- 
dies Mentales,  noted  the  fatal  nature  of  parah^sis  with 
failure  of  speech,  but  he  also  did  not  have  a  clear  con- 
ception of  general  paresis  as  a  distinct  type  of  disease. 
It  is  to  the  pupils  of  Esquirol  that  the  distinction 
belongs  of  actuall}'  bringing  to  light  this  much-dis- 
puted disease.  Georget  (1820)  described  it  under 
the  name  of  chronic  muscular  paralysis.  Bayle 
(1822)  referred  both  the  muscular  and  mental  symp- 
toms in  these  cases  to  arachnitis  or  chronic  menin- 
gitis, and  later  (1825)  he  observed  the  changes  in 
speech  and  the  motor  disorders.  About  the  same 
time  (1824)  Delaye  wrote  of  it  under  the  title  of 
incomplete  general  paralysis,  believing  that  it  was  a 
softening  or  atrophy  of  the  brain  with  adhesions  of 
the  membranes.  In  1826,  Calmeil,  another  pupil  of 
Esquirol,  published  a  complete  account  of  the  phys- 
ical symptoms  and  anatomical  lesions  of  general 
paresis,  under  the  title  of  paralysis  observed  in  the 
insane.  The  subject  was  studied  with  much  zeal  by 
these  observers,  and  especially  by  Calmeil,  to  whom 
is  frequently  ascribed  the  merit  of  having  been  the 
discoverer  of  it.  Georget,  Delaye  and  Calmeil  re- 
garded the  malady  as  a  special  form  of  paralysis 
superimposed  upon  the  insanity,  that  is,  as  a  compli- 
cation of  an  already  existing  disease.  Bayle,  on  the 
contrary,  formulated  a  new  theory,  declaring  the 
affection  to  be  a  distinct  entit}-;  he  made  expansive 
delusions  its  necessary  characteristic  symptom,  assign- 
ing it  a  regular  course  and  dividing  it  into  three  suc- 
cessive periods  —  monomania,  mania  and  dementia. 
Both   Bayle  and  Calmeil   were   of  the   same    belief 


20  INTRODUCTORY. 

respecting  the  anatomico-pathological  characters,  in 
considering  pathognomonic  the  adhesions  existing 
between  the  meninges  and  the  convolutions. 

The  views  of  Bayle  gained  ground  slowly,  and  in 
1838  Parchappe,  a  prominent  observer,  reached  the 
conclusion,  also,  that  general  paresis  was  a  distinct 
form  of  insanity,  with  characteristic  symptoms  of 
motor  and  mental  disorder,  which  he  designated  as 
paralytic  insanit3\  Requin  (1846)  proposed  a  restric- 
tion of  this  view.  He  contended  that  the  malady,  to 
which  he  applied  the  prefix  "  progressive,"  may  exist 
without  mental  symptoms,  conceiving  the  paralysis  to 
constitute  the  essential  part  of  the  disease,  although  a 
certain  degree  of  dementia  was  admitted  to  be  the 
customary  sequel  of  the  paralysis.  This  theory  was 
further  confirmed  by  other  able  writers,  such  as  San- 
dras,  Lunier  and  Baillarger.  The  latter,  who  took 
an  important  place  in  the  discussions  for  many  years, 
claimed  that  the  dementia  and  not  the  delusion  was  the 
chief  symptom  of  the  disease,  and  (1846)  he  it  was  who 
first  called  it  paralytic  dementia,  a  name  which  has 
been  adopted  by  many  writers  even  to  the  present  day. 

From  this  time  forth  investigators  multipl}',  and 
numerous  become  the  writers  on  the  subject.  In 
1858  a  long  and  animated  discussion  took  place  in 
the  French  Medico-Psychological  Society,  which 
confirmed  the  principle  of  the  essentiality  of  general 
paralysis.  For  a  long  time  the  clinical  analysis  of 
the  disorder  occupied  the  attention  of  the  authorities, 
but  of  late  years  the  investigations  have  been  directed 
more  to  the  pathology  of  the  affection. 

In  the  latter  part  of  his  career,  Baillarger  returned  to 
"  the  dualist  theory,  which  he  at  one  time  abandoned, 
that  admits  the  existence  of  two  quite  distinct  disor- 
ders, susceptible  of  existing  associated  with  each  other, 
or  separately:    (i)  Paralytic  dementia,  the  principal 


INTRODUCTORY.  21 

disease ;  (2)  paralytic  insanity,  the  accessory  affec- 
tion" (Regis).  The  adherents  of  this  theory  are 
to-day  numerous. -"^ 

Again,  some  authors,  for  instance,  M.  Ball  of  Paris, 
look  upon  general  paresis,  as  a  generic  term,  embrac- 
ing a  variety  of  diseases,  differing  in  etiology,  symp- 
toms, course  and  final  termination. 

Hence,  we  see  that  there  have  been  in  the  past  sev- 
eral theories  respecting  the  nature  of  general  paresis,  of 
which  the  prominent  ones  may  be  briefly  stated  thus : 

1.  As  a  complication  of  insanity: 

2.  As  a  distinct  form  of  insanity; 

3.  If  not  as  a  group  of  cerebral  or  cerebro-spinal 
affections,  at  least  as  a  paralytic  dementia,  to  which 
is  associated  more  or  less  frequently,  and  under  various 
conditions,  insanity  (Regis)." 

As  an  illustration  of  the  former  rarity  of  this  dis- 
ease in  this  country,  it  is  said  that  the  eminent 
alienist,  the  late  Dr.  Luther  Bell,  of  Massachusetts, 
at  the  time  of  his  first  visit  to  England,  about  fifty 
years  ago,  had  never  recognized  a  case  of  general 
paresis,  a  statement  which  seems  almost  incredible 
considering  its  rapid  increase  and  spread  in  late 
years,  especially  during  the  past  quarter  of  a  century. 

1"  One  of  the  questions  which  general  physicians  ask  is,  whether  this 
same  disease,  which  is  called  general  paralysis,  can  exist  without  mental 
disorder.  I  always  reply  that  I  have  seen  several  cases  who  for  years  have 
exhibited  bodily  symptoms  in  every  particular  coinciding  with  those  found 
in  the  patients  in  our  asylums  suffering  from  general  paralysis  of  the 
insane,  and  yet  without  the  slightest  evidence  of  insanity,  even  without 
any  loss  of  memorj^  or  self-control ;  so  that,  in  fact,  the  patient  was  sound 
in  mind  although  a  general  paralytic  in  body.  The  reason,  1  believe,  that 
the  condition  has  hitherto  been  misunderstood  is,  that  asylum  physicians 
rarely  see  cases  in  general  hospitals  ;  and  general  physicians  only  occa- 
sionally have  the  chance  of  watching  true  general  paralysis.  In  my  opin- 
ion, general  paralysis  may  develop  in  any  of  its  forms  without  mental 
symptoms  for  a  considerable  length  of  time  ;  but  unless  cut  short  by  some 
intercurrent  or  accidental  cause,  mental  deterioration  shows  itself  before 
the  end.  The  symptoms  may  be  only  those  of  weak-mindedness,  and  may 
be  so  slight  that  comparatively  little  importance  is  attached  to  them." 
(Savage  on  Insanity,  p.  277.) 

2 Mental  Diseases,  Bannister's  translation. 


CHAPTER   11. 

GENERAL    PARESIS. 

Synonyms. — General  Paresis,  Paresis;  General 
Paralysis,  General  Paralysis  of  the  Insane;  Paretic 
Dementia,  Dementia  Paralytica  (Krafft-Ebing),Para- 
l\tic  Dementia;  Progressive  Paralysis  of  the  Insane. 

Other  Titles :  Progressive  General  Paralysis;  Pro- 
gressive General  Paresis:  Paralvtic  Insanitv;  Progres- 
sive  Paralysis;  Diffuse  Interstitial  Periencephalitis; 
Paralysie  Generale  des  Alienes;  Folic  Parah'tique; 
Periencephalo-^NIeningitis  Diffusa  Chronica  (Cal- 
meil)  ;  Paralyse  der  Irren;  Paralytischer  Blodsinn; 
Allgemeine  Paralyse  der  Geisteskranken;  Psicopatia 
Paralitica  (Morselli). 

Definition. — General  paresis  is  a  subacute,  or 
chronic,  degenerative  disease  of  the  brain,  often 
extending  to  the  spinal  cord  and  the  large  nerve 
trunks.  It  is  marked  chiefly  by  progressive  en- 
feeblement  of  the  mind  and  concomitant  paresis  of 
the  entire  body.  Mentally,  there  is  moral  and  intel- 
lectual perversion,  with  an  abnormal  sense  of  well- 
being,  or  actual  delusions  of  exaltation,  followed  by 
slow  dementia,  to  which  is  generally  superadded 
insanity  of  the  maniacal,  melancholic,  or  confusional 
type ;  physically,  there  is  gradual  development  of 
tremor,  pupillary  changes,  loss  of  coordinating  power, 
especially  of  speech  and  gait,  trophic  complications, 
occasional  epileptiform  or  apoplectiform  seizures,  and 
finally  paresis. 

The  Mode  of  Commencement. — The  very  early  indica- 
tions of  general  paresis  are  frequently  so  ill  defined  as  to 


STAGES    OF    GENERAL    PARESIS.  23 

escape  recognition,  and  their  true  import,  even  by  a 
competent  observer,  cannot  always  be  estimated,  the 
difficulty  being  less  when  they  are  more  or  less  sig- 
nificant, and  the  ensemble  receives  due  consideration. 

There  are  two  accepted  forms  of  onset — the  grad- 
ual and  the  sudden.  In  the  latter,  there  is  nothing 
to  warn  before  "  the  storm  has  broken."  A  sudden 
attack  of  acute  mania  may  be  the  precursor;  or  a 
variety  of  cerebral  seizure,  such  as  an  epileptiform, 
or  apoplectiform  attack.  Some  writers  believe  that 
in  these  attacks  and,  also,  in  the  cases  where  a  violent 
shock  or  an  accident  appeared  to  be  the  beginning, 
the  real  beginning  was  much  earlier  and 'to  be  sought 
in  some  of  the  vague  warnings  enumerated  in  the 
prodromes.  According  to  these  observers,  and  with 
plausibility,  the  beginning  of  the  disease  is  seldom 
sudden  in  onset. 

It  should  be  kept  in  view  that  the  changes  at  first 
are  inconsequential  when  taken  by  themselves,  but 
grow  gradually  more  distinct  in  the  progress  of  the 
invasion.  The  course  of  the  disease  depends,  also, 
on  its  type,  whether  (<2)  depressive,  (3)  expansive, 
or  (c)  demented;  many  cases  are  earl}^  tinged  with  a 
slightly  somber  or  melancholy  aspect,  which  may 
pass  unnoticed. 

Stages  of  General  Paresis. — It  has  been  customary 
for  authors  to  divide  this  disease  into  stages,  but  there 
is  considerable  variation  in  these  classifications;  some 
writers  make  only  two  or  three  divisions,  others  four  or 
five.  It  may  be  seen,  therefore,  from  this  diversity  that 
these  divisions  are  merely  artificial  and  that  the  demar- 
cations are  not  readily  discerned  in  practice.  There 
is,  too,  not  much  utility  in  this  classification,  excepting 
as  it  may  be  of  aid  in  the  study  of  its  evolution,  and  for 
purposes  of  clinical  description.  But  here  even  this 
separation  of  the  disease  into  stadia  may  be  accounted 


24  GENERAL    PARESIS. 

by  some  as  of  limited  value,  because  of  the  wide 
diversity  of  its  course.  In  some  cases  no  distinct 
stage  can  be  traced;  in  some  the  ph3-sical  symptoms 
are  prominent  from  the  beginning,  in  others  not; 
sometimes  the  course  is  rapid,  at  other  times  it  is 
slow;  and  so  too  with  the  epiphenomena,  they  may 
be  present  or  absent  in  varying  degree. 

In  these  pages,  for  the  reasons  above  mentioned, 
the  plan  has  been  chosen,  of  making  four  typical 
divisions,  which  correspond  to  the  following  order: 

1.  A  prodromal  stage,  or  period  of  moral  and 
mental  alteration. 

2.  A  stage  of  decided  mental  alienation,  or  of 
dementia  only. 

3.  A  stage  of  chronic  mental  disorder. 

4.  A  stage  of  fatuity  (Mickle). 
Or  thus  expressed: 

1.  A  prodromal  stage. 

2.  That  of  fibrillar  tremblings  and  slight  incoordi- 
nation of  the  muscles  of  speech  and  facial  expression, 
and  of  mental  exaltation  with  excitement. 

3.  That  of  muscular  incoordination  and  paresis, 
with  mental  enfeeblement. 

4.  That  of  advanced  paresis,  with  little  power  of 
progression,  almost  inarticulate  speech,  and  at  last 
paralysis,  with  mental  extinction  (Clouston). 

A  HYPOTHETICAL   CASE  OF    GENERAL   PARESIS   IN   THE  PRO- 
DROMAL STAGE. 

Male,  40  to  45  years  old,  single,  of  robust  habit  and 
good  previous  general  health,  (in  some  cases  a  syphilitic 
history  may  be  obtained)  ;  no  distinct  insane  ancestry ;  of 
sanguine  temperament.  Mentally  intelligent,  more  rarely 
accomplished  or  highly  educated  ;  active,  energetic,  specu- 
lative, sanguine  of  success  ;  disposed  to  be  changeable  and 
fickle.  Fond  of  society,  a  bon-vivant,  and  self-indulgent 
in  every  way  with  tendency  to  excesses  in  drink  and  sexual 


STAGES    OF    GENERAL    PARESIS.  25 

indulgences.  After  a  sudden  reverse  in  hopes,  preceded  by 
a  period  of  mental  strain,  patient  shows  change  in  character 
and  conduct ;  rarely,  by  great  depression,  usually  by  an 
unusual  mental  excitement,  often  amounting  to  a  distinct 
elation.  The  patient's  spirits  are  high,  such  as  an  extra 
glass  of  alcoholic  stimulant  would  give.  The  patient  busies 
himself  in  various  matters,  exhibiting  a  constant  garrulity 
and  an  entire  absence  of  reticence,  with  egotistical  brag- 
ging ;  he  will  button-hole  persons,  almost  strangers,  and 
relate  to  them  his  confidences.  He  exhibits  very  little 
physical  change  at  this  epoch.  His  elevation  may  lead 
him  to  social  indulgences  or  drink,  (thus,  alteration  in 
behavior  is  frequently  ascribed  to  intoxication).  Mental 
character  is  one  of  restlessness,  followed  by  mental  con- 
fusion ;  patient  makes  y^//'.v_^(75  of  various  kinds,  such  as 
shown  in  the  following  incidents.  A  gentleman  walked 
into  a  drawing  room  without  removing  his  hat  and  lighted 
.  a  cigar.  A  poor  woman  openly  stole  some  plants  from  a 
window.  A  woman  coming  out  of  a  church  took  a  hand- 
ful of  silver  from  a  plate  held  at  the  door  without  any 
attempt  at  concealment.  A  married  woman  began  to  un- 
dress herself  by  a  countr}-  roadside.  A  woman  ordered  a 
pair  of  breeches  for  her  husband,  a  bricklayer,  to  be  made 
of  moire  antique.  (Abstract,  Sankey,  Lectures  on  ]\Iental 
Disease,  p.  255.) 

TYPICAL    CASE    OF    GENERAL    PARESIS    IN    A    MAN. 

Clarence  E.,  married,  aged  37  ;  wine  merchant.  No  in- 
sane relatives  ;  not  very  sober  habits.  Anxiety  the  supposed 
cause  for  this  first  attack  of  insanitv.  He  had  followed 
many  different  occupations  during  his  life.  He  had  had 
a  fit  before  admission.  On  admission,  he  had  mania  with 
exaltation:  imagined  he  was  the  eldest  son  of  God;  was 
formerly  a  great  duke ;  and  had  unbounded  wealth  ;  also 
said  that  he  slept  twentv  to  sixtv  hours  a  night.  Occa- 
sionally he  would  say  that  he  had  lost  all  his  delusions,  but 
it  required  only  a  short  conversation  to  get  evidence  of 
their  persistence.  He  could  not  appreciate  facts.  He  lost 
strength  and  flesh  rapidly  during  the  first  few  months  of 


26  GENERAL    PARESIS. 

his  admission,  and  there  was  an  increase  of  tremulousness 
in  his  facial  and  lingual  muscles.  He  walked  about  rest- 
lessly for  hours  and  wrote  endless  letters  to  great  people. 
His  memory  was  markedly  affected  and  his  sense  of  color 
was  changed.  Six  months  after  admission,  for  a  few  days, 
his  speech  became  affected,  and  there  was  loss  of  power  in 
his  extremities,  but  there  were  no  distinct  convulsions.  He 
recovered  from  this  and  ate  and  slept  well.  He  had  pneu- 
monia in  about  a  year  after  admission.  During  the  next 
year  he  was  much  better,  walked  in  the  garden.  How- 
ever, his  handwriting  was  shaky,  and  early  in  the  next 
year,  two  and  a  half  years  after  admission,  his  aspect  be- 
came dull  and  expressionless.  He  was  unsteady  in  his 
gait  and  on  several  occasions  fell,  but  his  muscles  were 
fairly  well  developed.  His  memory  was  failing  and  he 
was  easily  moved  to  tears.  His  average  temperature  was 
98.4°  in  the  morning  and  100°  at  night;  he  had  no  control 
over  rectum  and  bladder,  and  had  loss  of  sensibility.  In 
May  of  the  same  year,  he  had  a  convulsive  fit,  from  which 
he  recovered,  and  for  a  month  afterward  gained  flesh. 
In  the  following  year,  he  was  fat,  flabby  and  demented, 
unable  to  stand ;  reflexes  very  exaggerated ;  appetite 
good  ;  limbs  somewhat  contracted  ;  right  pupil  large  ;  he 
laughed  senselessly  when  spoken  to  and  resisted  interfer- 
ence. He  was  threatened  with  bed-sores.  In  latter  part 
of  same  year,  he  had  severe  convulsion  affecting  right 
side  ;  he  recovered,  but  was  in  every  way  weaker,  legs 
becoming  contracted  and  he  ground  his  teeth.  During  the 
next  year  and  as  long  as  he  lived  he  never  regained  con- 
sciousness ;  swallowed  food  automatically  but  never  artic- 
ulated. Optic  discs  were  pale  and  atrophied,  but  he  could 
hear  and  see  a  little.  He  remained  in  bed,  his  limbs 
drawn  up,  till  August,  when  he  had  a  fit  which  was  pre- 
ceded by  a  condition  of  extreme  reflex  irritability  ;  head  was 
drawn  to  right  side  ;  right  pupil  was  large  ;  he  had  clonic 
spasms  of  lower  jaw  and  occipito-frontalis  muscle.  He 
recovered  from  this,  but  died,  worn  out,  in  March  of  the 
following  year,  about  five  and  a  half  years  after  admis- 
sion.     (Abstract,  Savage  on  Insanity,  p.  299.) 


CHAPTER   III. 

THE    SYMPTOMS    OF    GENERAL    PARESIS. 

The  Prodromal  Stage.  {First  Period.)  Mental 
Symptoms. — There  is,  perhaps,  no  disease  that  begins 
more  gradually  than  general  paresis,  for  the  period 
of  inception,  although  varying  within  wide  limits,  may 
be  prolonged  over  months,  or  even  years.  If  one  has 
the  opportunity  to  observe  closely  the  life  of  the  pa- 
retic and  at  the  same  time  to  gather  from  his  friends 
all  of  the  data  obtainable,  it  need  not  cause  surprise 
to  find  that  the  first  changes  in  the  feelings,  the  intel- 
lect and  the  organic  functions  of  the  subject,  which 
mark  the  appreciable  beginning  of  the  disease,  extend 
into  the  past  for  many  months,  and  sometimes  for  a 
number  of  years,  prior  to  its  apparent  onset. 

At  first,  the  patient  is  conscious  of  feeling  that 
he  is  not  in  his  normal  condition,  but  as  the  disease 
advances,  he  loses  the  power  of  discrimination,  and 
he  then  insists  that  he  is  entirely  well.  Savage  refers 
to  a  physician  who  correctly  diagnosed  his  own  case 
as  that  of  paresis,  but  soon  forgot  his  misfortune  in 
the  blighting  effects  of  the  advancing  disease. 

In  another  case,  the  patient  pointed  to  the  top  of 
his  head,  and  said  that,  like  Swift,  he  was  "  going  first 
at  the  top."  For  the  moment  he  appeared  emotional, 
but  in  the  feeling  of  bien-etre,  which  was  developing, 
he  forgot  his  troubles,  when  induced  to  speak  of  his 
fine  capabilities.  Lewis  tells  of  a  talented  mathe- 
matician, in  whom  the  early  symptoms  were  intense 
despondency  and  sudden  lapse  of  attention  and  mem- 
ory.    Often  when  solving  a  problem,  he  would  cover 

27 


28  SYMPTOMS    OF    GENERAL    PARESIS. 

his  face  with  his  hands,  and  rising  from  his  chair  with 
a  pained  expression,  hurriedly  remark,  "  It's  of  no  use, 
it's  all  gone!"  He  frequently  confessed  how  painful 
such  a  state  was  to  him,  realizing  most  fully  the 
sad  condition  of  his  mind,  before  the  final  disruption 
occurred. 

In  former  years,  alienists  were  disposed  to  set  the 
limit  of  the  initial  stage  at  a  much  shorter  length 
than  experience  teaches  us  now  to  do.  Formerly,  it 
was  placed  at  two  or  three  years,  or  less ;  to-day,  it 
is  not  unusual  to  see  it  placed  at  eight  or  ten  years. 
There  is  a  preparalytic  period,  analogous  to  the  pre- 
taxic  period  of  tabes. 

Generally,  the  earliest  signs  observed  are  those  of 
mild  brain  failure,  indicated  by  a  somewhat  enfeebled 
state  of  the  mind.  This  mental  failure  is  shown  by  a 
change  in  the  disposition  and  character  of  the  patient, 
not  at  the  start  ver}-  pronounced,  but  soon  issuing  in 
habits  and  conduct  at  variance  with  his  normal  pro- 
clivities, which  become  more  and  more  bizarre  with 
the  lapse  of  time.  An  intelligent  merchant,  in  good 
social  standing,  acquired  an  ambition  to  become  a 
pugilist,  frequented  low  places  of  amusement  and 
taverns  and  became  acquainted  with  several  prize- 
fighters to  whom  he  paid  large  sums  to  be  allowed  to 
beat  them  (Spitzka).  The  change  of  character  may 
be  detected  also  in  some  loss  of  interest  by  him  in 
his  affairs,  or  in  an  impaired  ability  to  attend  regularly 
to  them.  There  is  some  obtundity  of  the  intellectual 
and  volitional  vigor  of  the  mind,  and  the  judgment  is 
more  or  less  clouded.  He  is  varyingly  absent-minded, 
indifferent,  apathetic,  or  negligent  in  both  his  domestic 
and  business  relations.  He  seems  unable  to  keep  his 
attention  for  a  length  of  time  to  an}'  fixed  purpose, 
albeit  he  can  follow  out  in  a  fairly  correct  manner 
the  routine  of  his  daily  life,  if  its  duties   be  not  too 


TUte  I. 


THE  PRODROMAL  STAGE. 
Since  1885  it  has  been  the  custom]to  photograph  systematicallj'  the  patients  at  the 
State  Hospital,  Norristown,  Pa.    From  this  large  collection  of  photographs  of  the  insane, 
these  and  most  of  the  succeeding  t>-pes  herein  shown,  have  been  selected  b\'  permission. 


THE    PRODROMAL    STAGE.  29 

intricate  or  exacting.  It  will  be  seen,  also,  that  he  is 
especially  deficient  in  initiative  action,  and  when  he 
actually  takes  up  a  new  project  his  attention  soon 
wanes,  and  his  interest  flags.  Moderate  exercise 
causes  unwonted  fatigue  of  mind  and  body,  which  if 
pressed  may  end  in  great  confusion  of  ideas.  Fol- 
som  observed  a  marked  change  for  the  worse  in  the 
tremor,  which  appeared  in  the  handwriting  of  a 
doubtful  case,  after  the  tiresome  effort  of  a  long 
walk;  and  Lewis  describes  a  case  where  the  man  was 
thrown  into  convulsions  by  pressing  him  into  close 
application,  in  the  solution  of  a  mathematical  prob- 
lem. 

Transitory  states  of  forgetfulness  uniformly  occur, 
to  which  cause  some  authorities  attribute  many  of  the 
inconsistencies  and  absurdities  that  characterize  the 
disease,  particularly  at  a  later  period.  It  is  related 
by  medical  jurists  that  a  physician  prescribed  sixteen 
grains  of  tartar  emetic,  instead  of  one  sixteenth  of  a 
grain,  and  a  Russian  doctor  was  sent  to  Siberia  for  a 
similar  mistake. 

There  is  loss  of  memory,  which  is  shown  in  many 
ways,  chiefly  for  recent  events  and  for  proper  names; 
it  is  seen  in  the  misspelling  of  words  when  writing, 
omitting  letters,  or  leaving  words  out  of  sentences; 
it  leads  to  incongruous  acts;  disregard  of  personal 
rights,  and  neglect  of  social  duties  and  courtesies. 
One  patient  sent  home  a  wagon-load  of  snow-shovels; 
another  bought  a  dozen  sets  of  weights  and  meas 
ures;  another  sent  out  agents  into  the  country  and 
purchased  all  the  turkeys'  eggs  he  could  get,  and  an- 
other drained  the  florists  of  tulip  bulbs.  A  gentle- 
man, as  an  early  S3'mptom,  stole  the  silver  forks  and 
spoons  from  the  tables  at  which  he  was  invited  to 
dine,  and  was  at  length  detected  with, a  silver  sugar- 
bowl  in  his  pocket  (Hammond).     "  We  see, in  short," 


30  SYMPTOMS    OF    GENERAL    PARESIS. 

says  Lewis,  "  in  his  whole  manner  of  life  a  weaken- 
ing of  mind,  such  as  may  be  noted  in  the  commence- 
ment of  senile  dementia,  but  which  occurring  in  a 
fine  and  vigorous  man  of,  it 'may  be,  thirty-five,  too 
surely  indicates  the  ruin  even  now  commencing." 

The  feelings  are  intensified  and  readily  stirred,  or 
are  excited  by  trivial  causes.  There  is  frequently, 
even  at  this  early  stage,  much  display  of  irritability, 
restlessness,  fickleness  and  temporary  loss  of  self- 
control  under  excitement;  and,  also,  a  change  in  the 
affections,  so  that  persons  previously  dear  to  the 
patient  may  become  hateful  to  him.  From  the  first, 
often  a  sense  of  well-being  is  present,  which  may 
issue  in  despondency  without  adequate  cause,  but 
just  as  frequently  in  sudden  alterations  of  mood  from 
one  extreme  to  another.  Innumerable  instances  of 
irritability  could  be  given.  A  paretic  was  turned  out 
of  the  theatre,  because  he  was  unable  to  show  his 
ticket  (having  in  his  amnesia  either  thrown  it  away 
or  forgotten  where  he  put  it)  and  then  broke  a  large 
pane  of  glass  to  climb  in  by  another  way  (Spitzka). 
Another,  at  a  fashionable  club,  of  which  he  was  a 
member,  finding  some  delay  in  getting  a  cigar,  impa- 
tientl}'  kicked  out  the  glass  of  the  case  and  began  to 
help  himself. 

Sometimes  the  forming  period  of  general  paresis 
is  called  the  medico-legal  stage,  because  of  the  moral 
perversion  so  commonly  seen  at  this  time,  which  may 
lead  the  person  into  difficulties  that  call  for  the  inter- 
vention of  the  law.  The  disease  not  being  recog- 
nized, the  patient  is  mistaken  for  the  ordinary  offender, 
and  not  until  he  has  been  arrested,  or  perchance  later, 
does  the  true  state  of  the  case  become  revealed.  De 
Boismont  gives  the  case  of  a  man  who  began  thieving 
eight  years  before  the  diagnosis  of  general  paresis 
was  made.     A  reputable  plumber,  among  the  writer's 


THE    PRODROMAL    STAGE.  3 1 

cases,  was  arrested  for  fraudulently  tapping  a  city  gas 
main,  without  a  certificate,  nearly  a  year  before  other 
discernible  symptoms  appeared.  In  another  case,  a 
sedate  married  man  was  arrested,  three  years  before 
he  was  adjudged  insane,  for  indecent  assault  on  a 
colored  woman,  and  he  was  emulged  of  a  large  sum 
of  money  before  released  from  his  unfortunate  plight. 
It  is,  therefore,  not  an  infrequent  experience  in  asylum 
life  to  receive  sufferers  of  this  disease  who  have  been 
subjected  to  the  ordeal  of  imprisonment  for  misde- 
meanor or  some  grade  of  crime. 

When  a  few  or  more  of  these  signs  have  existed 
for  a  variable  period,  the  true  nature  of  the  malady 
becomes  better  defined  by  symptoms  of  a  more  marked 
character.  The  sense  of  bien-etre  passes  into  a  gene- 
ral feeling  of  elation,  an  unbounded  egotism  shown  by 
the  exalted  opinion  that  the  patient  has  conceived  of 
his  attainments,  of  his  prowess,  or  of  his  social  and 
political  eminence.  The  elevated  feelings  beget  a 
restless  spirit,  inducing  unusual  and  useless  activity. 
It  especially  applies  to  the  ordinary  affairs  of  life;  there 
is  a  scheming  disposition,  which  leads  into  extrava- 
gance of  all  sorts  greatly  in  excess  of  the  patient's 
resources,  and  may  result  in  a  change  of  occupation. 
Generosity  and  avarice  go  hand  in  hand;  while  just 
debts  are  ignored  and  the  family  neglected,  articles  of 
doubtful  utility  are  bought  recklessly,  or  necessary 
ones  exchanged  for  those  of  no  value. 

It  will  be  perceived  that  these  signs  indicate  only 
an  alteration  in  the  character  of  the  individual,  brought 
about  by  a  mild  enfeeblement  of  the  mind,  requiring 
to  be  looked  for  sharply,  and  not  a  true  alienation. 
This  altered  condition  is  compatible,  as  we  have  seen, 
with  the  performance  of  customary  duties,  and  con- 
sequently may  readily  be  overlooked  by  the  casual 
acquaintance.     "  The  patient,"  Lewis  very  justly  says. 


32  SYMPTOMS    OF    GENERAL    PARESIS. 

"hovers  on  the  borderland  of  delusional  perversion. 
The  judgment  is  enfeebled  and  clouded — not  neces- 
sarily perverted — and  the  condition  is,  in  fact,  one  of 
over-balance." 

Prodromal  Stage.  i^First  Period?)  Physical  S3'mp- 
toms. — The  concomitant  physical  symptoms,  becom- 
ing progressively  graver,  should  be  sought  primarily 
in  some  of  the  indefinite  manifestations,  which,  taken 
alone,  may  be  misinterpreted  as  purely  of  a  functional 
nature,  or  lead  to  error  by  being  mistaken  for  those 
of  neurasthenia,  with  or  without  h3'steria,  or  uncom- 
plicated cerebral  asthenia.  Ballet  reports  that  one  of 
the  most  brilliant  French  novelists  of  recent  years 
was  energetically  treated,  for  several  months,  with 
douches,  as  a  neurasthenic,  before  the  obvious  signs 
of  general  paresis  were  observed.  Stearns  tells  of  a 
paretic,  who,  unable  to  attend  to  business  on  account 
of  restlessness,  was  treated  by  the  family  physician 
for  malaria. 

There  is  an  impressionable  state  of  the  vaso-motor 
system,  giving  rise  to  palpitation  with  flashes  of  heat 
to  the  head  and  alternate  pallor  and  redness  of  the 
face.  The  physiognomy,  in  some  cases,  changes;  the 
face,  then,  becomes  fat  and  loses  its  expression  and 
no  longer  reflects  accuratel}',  as  in  health,  the  work- 
ings of  the  mind.  Fleeting  pains  of  a  neuralgic  or 
rheumatic  character  are  felt  in  different  parts  of  the 
body,  or  the  pain  may  be  localized;  then  may  follow 
cardialgia,  epigastralgia  and  rhachialgia.  A  woman 
patient  had  had  neuralgic  pains  six  years  before  men- 
tal symptoms  appeared.  Whenever  these  pains  sub- 
sided, as  they  frequently  did,  there  occurred  numb- 
ness and,  at  times,  loss  of  sensation  in  feet  and  ankles 
(Stearns).  Insomnia  is  frequent;  sleep  being  either 
absent  for  longer  or  shorter  periods,  or  disturbed  by 
dreams  and  nightmares,  or  is  unrefreshing.     The  pa- 


THE    PRODROMAL    STAGE.  33 

tient  complains  of  general  malaise,  and  often  of  dull 
headache,  which  is  either  sincipital,  temporo-frontal, 
or  occipital.  Some  cases  speak  of  girdle  pains,  as  if 
tight  bands  were  being  drawn  round  the  head,  or 
round  the  body,  as  in  locomotor  ataxia.  Local  anes- 
thesias or  paresthesias  with  tingling  and  formication 
of  the  skin  are  not  uncommon,  as  well  as  various 
painful  sensations,  of  heat,  of  cold,  and  of  pressure; 
loss  of  sight,  optic  neuritis;  affections  of  hearing; 
alterations  in  the  senses  of  taste  and  smell;  and 
sometimes  sensations  of  electric  currents  in  the  head. 
Some  patients  have  the  feeling  that  they  are  walking 
on  air,  and  experience  little  or  no  fatigue  after  much 
exercise;  others  are  dull,  heavy,  and  are  easily  tired 
without  receiving  relief  from  rest  in  bed.  Vertiginous 
attacks  occur,  but  when  mild  they  are  liable  to  escape 
attention;  also  hummings,  whistlings,  and  sounds  of 
bells  in  the  ears;  and  almost  always  there  is  an  ab- 
normal reaction  to  alcohol  and  drugs. 

There  may  be  digestive  disorders,  such  as  gastric 
crises  (Hurd),  capricious  appetite  and  irregular  action 
of  the  bowels.  The  circulation  is  sluggish  and  there 
is  often  a  dull  leaden  color  to  the  skin,  as  seen  in 
persons  who  suffer  from  hepatic  disorders. 

In  the  female,  dysmenorrhea  and  amenorrhea  are 
often  noticed,  the  latter  more  frequently  than  the 
former. 

At  this  early  period,  even,  there  may  appear  motor 
troubles  which  from  a  diagnostic  point  are  most  sig- 
nificant. Among  these  may  be  mentioned  a  tremor 
of  the  muscles  about  the  mouth  and  naso-labial  folds; 
a  fine  fibrillary  quivering  of  the  tongue,  or  a  coarser 
twitching  of  individual  fibres;  and  an  incoordinate 
jerky  protrusion  of  it  under  voluntary  effort.  A 
slight  slur  or  hesitation  in  the  speech  may  sometimes 
be  detected.     Pupillary  anomalies  (contracted,  irreg- 


34  SYMPTOMS    OF    GEXICRAT.    I'Al^ESIS. 

ular,  sluggish,  or  unequal  pupils)  may  also  coexist, 
or  may  antedate  other  symptoms  for  a  long  time 
(Griesinger).  In  one  of  Campbell  Clark's  cases  the 
only  motor  symptoms  observed  for  years  were  small 
pupils,  tremor  of  the  tongue  and  of  the  left  depressor 
ahnc  nasi.  Not  least  in  value,  as  forming  a  highly 
pertinent  group  of  symptoms,  are  certain  epilepti- 
form, or  apoplectiform  seizures,  which,  occurring  at 
any  stage,  are  grave  forebears.  In  point,  Folsom 
relates  these  two  interesting  cases:  An  express- 
delivery  driver  had  epileptiform  seizures  for  five 
3^ears  before  he  became  so  forgetful  and  inattentive 
that  he  was  discharged.  He  then  had  other  svmp- 
toms  of  general  paresis;  a  prodromal  period  of  five 
years  resulted  in  this  case.  A  Boston  ladv  was  treated 
in  the  Isle  of  Wight,  for  four  years  with  bromides  for 
epilepsy.  After  her  return  home,  she  was  supposed 
to  have  nervous  prostration  and  convulsive  attacks  ot 
hysterical  origin.  A  diagnosis  of  general  paresis  was 
made  by  Folsom,  and  her  subsequent  career  proved 
it  to  be  correct. 

Some  of  the  authorities,  from  two  of  whom  these 
selections  have  been  made,  tersely  summarize  the 
prodromal  symptoms :  Take  note  of  earl}^  fatigue, 
fainting  or  other  fits,  loss  of  smell,  vague  optic  disc 
changes,  unaccountable  knee  phenomena,  unusual 
headaches,  neuralgia  and  sciatica,  changes  of  char- 
acter, progressive  loss  of  the  highest  control,  moral 
lapses  and  instability  in  various  forms  (Savage). 

When  a  man  in  early  middle  life  comes  before  us 
who  has  shown  a  recent  alteration  in  his  whole  char- 
acter, restlessness,  irritability,  together  with  utter 
indifference  to  the  needs  of  others,  and  pronounced 
egoism;  and  when  on  examination  we  can  demon- 
strate the  presence  of  pupillary  anomalies  and  abnor- 
malities in   the   deep  reflexes,   we  are  fairly  safe  in 


THE    PRODROMAL    STAGE.  35 

concluding    that   we    have    to    deal    with    a    paretic 
(Berkley). 

A    CASE  OF    GENERAL  PARESIS    IN    THE  PRODROMAL    STAGE. 

A  patient,  ast.  46,  had  been  in  an  asylum  a  week,  hav- 
ing been  brought  over  from  Ireland.  No  stutter  in  speech, 
no  irregularity  of  pupil,  no  contraction  or  dilatation.  He 
had  full  power  and  perfect  coordination  of  both  hands  and 
feet.  He  could  play  billiards  and  the  piano  well ;  walked 
with  a  long  swinging  stride,  which  was  possibly  habitual. 
Speaking  generally,  the  bodily  signs  of  general  paralysis 
were  absent.  Mental  symptoms  afforded  more  information, 
although  these  were  not  very  marked.  He  had  no  very  ex- 
travagant delusions,  thought  himself  wonderfully  lucky,  as 
he  had  bought  five  or  six  horses  for  small  sums  from  which 
he  was  to  realize  some  hundreds.  He  was  gay  and  jocose, 
on  the  best  of  terms  with  his  friends  ;  he  showed  loss  of 
memory,  for  he  said  that  he  had  left  Ireland  three  weeks  be- 
fore, whereas  it  was  only  one.  Although  told  that  another 
physician  and  myself  were  doctors  come  to  examine  him,  he 
never  tried  to  persuade  us  to  let  him  go,  though  he  said  he 
was  quite  w^ell  and  needed  no  doctors.  He  was  pronounced 
paralytic  :  (i)  On  account  of  the  peculiar  "  larkiness  "  and 
hilarity  exhibited  to  two  perfect  strangers  who  had  come 
to  examine  him  ;  (2)  his  self-satisfaction  and  ideas  of  gen- 
eral good  luck  and  success  ;  (3)  his  indifference  with  regard 
to  being  released ;  (4)  his  loss  of  memory.  (Abstract, 
Blanford,  Insanity  and  its  Treatment,  p.  302.) 

A  CASE  OF  GENERAL  PARESIS  IN  THE  PRODROMAL  STAGE. 

A  man  forty-five  years  old,  vigorous,  married,  of  a 
healthy  family  ;  never  had  serious  illness  ;  denied  history 
of  syphilis.  An  extraordinary  salesman  with  a  salary  of 
$4,500  per  year;  he  lost  his  position,  because  he  had  lost 
his  faculty  of  making  ready  sales.  His  wife  found  that  he 
had  not  saved  any  money,  that  he  could  not  tell  what  had 
become  of  it,  and  that  he  could  not  be  depended  upon  to 
earn  anything.  He  became  indifferent  rather  than  idle  ; 
placid,   apathetic,   absent-minded,  unenergetic ;    therefore 


36  SYMPTOMS    OF    GENERAL    PARESIS. 

he  could  not  get  a  position.  He  performed  the  ordinary 
duties  of  the  house.  Subsequently,  he  went  to  the  door 
inadequately  dressed,  and  in  other  respects  he  showed  a 
lack  of  a  sense  of  delicacy,  but  he  did  not  realize  it.  He 
became  inconsiderate  of  his  wife,  and  he  showed  de- 
creased sexual  power,  and  increased  desire.  Upon  ex- 
amination, it  was  found  that  he  could  converse  intel- 
ligently ;  he  had  lost  some  flesh  and  strength,  but  had 
good  appetite.  Unnaturally  deliberate  in  conversation,- 
somewhat  sluggish  in  speech ;  a  lack  of  animation ;  a 
failure  in  quickness  of  memory  and  intellectual  prompt- 
ness such  as  no  one  worth  $4,500  a  year  would  have. 
On  this  account,  he  went  to  an  asylum,  where  marked 
intellectual  impairment  soon  appeared.  He  died  a  pa- 
retic. (Abstract,  Folsom,  Rept.  Trans.  Assoc.  Amer. 
Phys.,  p.  6.) 

A  CASE    OF   GENERAL    PARESIS  IN    THE    PRODROMAL   STAGE. 

A  strong,  healthy  man  in  prime  of  life,  had  overworked 
himself  to  get  education  ;  became  successful  lawyer  ;  mar- 
ried, three  children  and  lived  well.  He  was  made  mayor 
of  his  city,  and  chairman  of  local  Republican  committee  ;  a 
witty  and  fluent  speaker,  in  better  spirits  than  usual.  It 
was  afterward  noticed  that  he  lacked  his  usual  good  sense 
and  judgment.  He  grew  careless  in  business,  and  slighted 
his  friends,  so  that  he  became  very  unpopular.  On  one  oc- 
casion, promising  to  speak  at  a  Republican  party  meeting, 
he  w^ent  to  another  city  and  spoke  before  the  opposition, 
ably  denouncing  his  own  party,  but  never  giving  an  ex- 
planation for  disappointing  the  audience  before  which  he 
had  promised  to  speak.  His  business  letters  needed  to  be 
revised  before  leaving  the  office.  His  mistakes  were  sup- 
posed to  be  due  to  his  many  outside  interests.  He  was  coun- 
sel in  a  contested  will  case,  involving  millions,  two  years 
after  the  beginning  of  the  symptoms  just  related.  Phys- 
ical weakness  was  the  only  S3'mptom  to  suggest  possible 
illness  to  his  family  ;  he  had  fallen  once  or  twice  in  the 
street ;  and  had  once  been  faint  and  prostrated  for  several 
minutes.       Finally,   a  consultation    was    held,    his    house 


THE    PRODROMAL    STAGE.  37 

was  turned  into  a  hospital,  and  he  died  a  typical  case  of 
general  paresis.     (Abstract,  Folsom,  ibid.,  p.  7.) 

A  CASE  OF  GENERAL  PARESIS  IN  THE  PRODROMAL  STAGE. 

An  English  actor,  robust  frame  and  healthy.  His  wife 
observed  that  he  could  not  commit  or  play  new  parts  ;  lost 
animation  and  force  in  his  accustomed  parts  ;  with  no  con- 
spicuous faults  lost  his  position.  Irritable,  indifferent,  apa- 
thetic; slow  in  mental  and  physical  action;  deliberate, 
tardy  speech  ;  facial  expression  lost  in  interest  and  force  ; 
he  had  beginning  atrophy  of  both  optic  discs.  One  year 
afterward,  he  began  to  show  ataxia  and  personal  exalta- 
tion ;  and  he  was  finally  sent  to  an  asylum,  where  he  soon 
died.     (Abstract,  Folsom,  ibid.,  p.  12.) 

A  CASE  OF  GENERAL  PARESIS  IN  THE  PRODROMAL  STAGE. 

C.  D.,  male;  set.  38;  family  history  negative;  duration 
of  disease  two  or  three  years.  Friends  have  noticed  for 
some  time  that  he  has  been  erratic  and  subject  to  loss  of 
control ;  he  was  easily  excited  to  anger  or  violence  ;  he  is 
rather  forgetful ;  he  has  lost  interest  in  his  personal  affairs  ; 
no  mental  symptoms  present.  He  shows  the  fatuous  ex- 
pression common  to  the  disease,  tremor  of  tongue  and  face 
(slightly) ;  speech  clumsy.  He  has  had  two  or  three  attacks 
of  aphasia  lasting  for  several  hours  to  a  day ;  his  physical 
condition  is  good  and  at  times  there  seems  to  be  great  im- 
provement in  all  the  symptoms.  (Abstract,  Fisher,  E.  D., 
Journal  of  Nervous  and  Mental  Diseases,  Vol,  18,  p.  825.) 

A    CASE    OF    GENERAL    PARESIS    SHOWING    MOTOR 

SYMPTOMS    FOR    A    LONG    TIME  WITHOUT 

MENTAL    IMPAIRMENT. 

Married  man,  «t.  38  (no  insanity  in  his  famil}^),  active 
and  industrious.  Noticed  a  change  in  his  handwriting  and 
hesitation  in  his  speech.  Pupils  were  unequal,  tongue 
tremulous,  handwriting  shaky,  with  a  tendency  to  drop 
terminal  letters  of  words.  Increased  patella  reflex,  but  no 
change  in  his  mental  capacity.  Memory  good  ;  he  was  not 
emotional,  and  he  had  not  lost  any  power  of  self-control. 


38  SYMPTOMS    OF    GENERAL    PARESIS. 

He  has  been  under  observation  for  years  and  has  shown 
no  intellectual  disturbance  ;  he  is  now  earning  his  living 
(Savage). 

SYMPTOMS    OF    DEPRESSION    IN    THE    PRODROMAL    STAGE 
FOLLOWED    BY    REMISSION    OF    SOME    MONTHS. 

In  one  case,  the  symptoms,  which  were  of  weakness  and 
depression,  but  unmistakably  those  of  general  paralysis, 
passed  off,  and  allowed  the  clergyman  to  perform  his 
duties  perfectly  for  some  months  before  he  again  broke 
down.  (Abstract,  Savage,  Trans.  Ninth  Inter.  Med. 
Cong.,  Vol.  5,  p.  400.) 

A    CASE    IN    WHICH     THE    DISEASE    WAS    NOT    AT    FIRST 

SUSPECTED.        GRANDIOSE    DELUSIONS    FOR 

FIVE    YEARS    WITHOUT    MARKED 

MOTOR    SYMPTOMS. 

R.  S.,  aet.  36,  had  been  in  America  for  some  years. 
On  admission  he  thought  he  was  a  general  and  that  he 
owned  property  in  the  neighborhood,  and  shares  in  several 
companies.  The  only  motor  symptoms  observed  for  years 
were  small  pupils,  tremor  of  the  tongue,  and  of  the  left 
depressor  alas  nasi.  There  were  cicatrices,  skin  eruptions 
and  other  conditions  suggestive  of  syphilis  but  not  very  con- 
clusive. He  suffered  from  strange  sensations,  particularly, 
he  averred,  at  the  sight  of  these  cicatrices,  a  feeling  as  if 
a  battery  were  connected  with  these  spots.  He  w^anted 
mustard  for  his  mouth  "  to  heat  the  nerve."  Developed 
delusions  of  persecution ;  he  became  more  and  more  shaky 
and  tremulous ;  he  had  an  attack  of  right  hemiplegia,  after 
which  his  speech  became  more  affected,  and  from  that  time 
onward  the  downward  general  paralytic  course  was  rapid. 
He  died  after  being  nine  years  insane.  (Abstract,  Camp- 
bell Clark,  Mental  Disease,  p.  223.) 

IRRITABILITY    AND  INDIFFERENCE  TO  PERSONAL  INTEREST 
OCCURRING  AS  PRODROMAL  SYMPTOMS. 

A  patient  had  a  physical  encounter  wnth  an  expressman 
for  leaving  one  of  his  trunks  on  the  street  instead  of  imme- 


THE    PRODROMAL    STAGE.  39 

diately  carrying  it  in.  On  finding  himself  in  the  asylum, 
he  walked  up  to  the  scales  to  be  weighed  with  an  air  of 
bravado,  and  said  he  was  glad  of  a  chance  to  be  weighed 
"  gratis."     (Abstract,  Spitzka  on  Insanity,  p.  189.) 

IRRITABILITY  AND  INDIFFERENCE    TO  PERSONAL    INTEREST 
AS  EARLY  SYMPTOMS. 

A  patient,  who  threw  his  knife  at  the  servant  because 
she  removed  his  plate  before  he  had,  as  he  alleged,  fin- 
ished dining,  heard  umoved,  a  few  hours  later,  of  a  loss  of 
$100,000  to  himself.     (Abstract,  Spitzka,  of.  cit.,'^.  189.) 

INSTANCE    OF    IRRITABILITY    IN    A    PARETIC    AN    EARLY 
SYMPTOM. 

A  man  threw  a  large  bottle  of  ink  at  his  brother  and 
business  partner  on  the  latter's  asking  him  the  meaning  of 
a  certain  entry  in  the  ledger.  (Abstract,  Spitzka,  op.  cit., 
p.  168.) 

PRODROMAL     SYMPTOMS    APPEARING     TEN     YEARS     BEFORE 
THE    DISEASE    HAD    BECOME    ESTABLISHED. 

The  wife  of  a  patient  said  that  for  ten  years  he  had  had 
extravagant  ideas  as  to  his  powers  of  money-making  and 
had  been  more  or  less  erratic,  and  irritable  and  occasion- 
ally he  gave  way  to  violent  temper.  (Abstract,  Sinkler, 
American  Journal  of  Insanity,  Vol.  45,  p.   79.) 

A    CASE    OF     GENERAL    PARESIS    WHERE     AT     OUTSET     THE 
MOTOR    SYMPTOMS    WERE    THE    MORE    PROMINENT. 

M.  E.,  ast.  41.  All  that  could  be  found  wrong  in  him 
mentally  a  year  ago  was  in  his  manner  and  carriage  rather 
than  in  anything  he  said.  He  looked  a  man  who  thought 
well  of  himself,  but  the  weakness  of  memory,  want  of 
method,  confusion  of  ideas  and  delusions  of  exalted  char- 
acter were  not  at  first  noticeable.  The  nervous  phenomena 
gave  a  clue  to  the  nature  of  the  case.  The  pupils  were 
equal,  contracted  regularly,  the  consensual  light  reflex 
slight  and  slow  ;  the  direct  light  reflex  was  good.  No  color- 
blindness ;  reflex  dilatation  impaired,  but  fairly  marked  on 


40  SYMPTOMS    OF    GENERAL    PARESIS. 

shouting  or  electrical  stimulation.  Smell  good,  hearing 
fairly  good.  Dynamometer  R.  lOO,  L.  90.  Knee  reflexes 
increased ;  superficial  reflexes  and  ankle  clonus  absent. 
Tongue  and  speech  tremulous,  and  the  facial  muscles 
showed  fine  tremors  when  he  was  the  least  excited.  A  few 
months  after  admission  he  had  a  faint  and  momentary  sei- 
zure, probably  epileptiform,  and  since  then  he  has  degener- 
ated mentally.    (x\bstract,  Campbell  Clark,  oj!*.  cit.^  p.  222.) 

A    CASE   OF   GENERAL    PARESIS    IN   THE    PRODROMAL    STAGE 
SHOWING    MORAL    PERVERSION. 

A  gentleman  in  prison  for  bigamy  ;  healthy,  40  yrs.  old, 
married,  good  character.  lie  was  sent  to  asylum  tw^o  years 
before,  because  he  had  married  a  young  girl  during  ab- 
sence from  home.  He  was  slightly  exhilarated  when  he 
entered  asylum  ;  talkative,  untidy,  no  motor  symptoms. 
Subsequently  his  natural  manner  returned,  and  he  was 
considered  well ;  he  was  removed  from  asylum  and  sent 
to  prison.  Here  it  was  found  that  he  was  inefficient  and 
that  he  could  not  concentrate  his  attention  continuously  in 
one  direction,  although  willing  to  do  what  he  was  ordered 
to  do.  In  time  he  could  not  carry  potatoes  from  store- 
room to  cook ;  he  became  very  indifferent.  Mental  and 
physical  strength  gradually  failed  and  after  two  years  it 
was  found  that  he  did  not  do  the  work  because  he  could 
not.  Folsom  found  him  to  be  a  general  paretic.  He  was 
sent  to  asylum  with  no  muscular  tremor,  or  embarrassed 
speech,  no  staggering  gait  or  exaltation.  Diagnosis  was 
disputed,  but  typical  symptoms  finally  appeared.  (Ab- 
stract, Folsom,  Rept.  Trans.  Assoc.  Amer.  Phys.,  p.  5.) 

GENERAL  PARESIS  IN  THE  PRODROMAL  STAGE  WITH 
MORAL  PERVERSION. 

One  patient,  an  eminent  lawyer,  who  had  at  one  time 
been  on  the  bench,  was  detected  in  stealing  engravings 
from  a  picture  dealer.  He  walked  out  of  the  shop  with 
the  prints  rolled  up  under  his  arm,  and  had  reached  the 
street  before  it  was  discovered  that  he  had  stolen  the  pic- 
tures.    (Abstract,  Hammond  on  Insanity,  p.  598.) 


CHAPTER   IV. 

SYMPTOMS    OF    GENERAL    PARESIS    {continued^. 

After  an  indefinite  prodromal  period,  the  disease, 
passing  into  the  next  stage  either  by  slow  gradations 
or  very  abruptly,  becomes  fully  established.  This  is 
called  the  first  stage  of  the  confirmed  affection,  which 
is  now  easily  recognizable,  as  a  rule,  b}'  the  develop- 
ment of  characteristic  mental^and  physical  symptoms. 

First  Stage  of  the  Established  Disease.  {^Second 
Period?)  The  Mental  Symptoms. — The  mental 
symptoms  of  this  stage  are  indicated  by  a  more  pro- 
nounced expression  of  those  described  as  belonging 
to  the  initial  stage.  The  patient  passes  from  a  condi- 
tion of  alteration,  as  before  described,  into  that  of 
alienation.  There  is  a  delusional  state  of  the  mind 
in  typical  cases,  which  is  characterized  by  the  under- 
lying condition  of  mental  enfeeblement.  If  the  transi- 
tion be  not  gradual,  or  precipitated  by  a  "  congestive 
seizure,"  there  is  then  usually  an  abrupt  issue  into  a 
maniacal  state,  accompanied  with  much  confusion  and 
vivid  hallucinations. 

Throughout  this  stage,  when  the  case  is  not  marked 
by  high  excitement,  there  is  commonly  a  delusional 
state  of  mind,  and  an  easy-going  self-satisfied  air,  in 
the  manner  of  the  patient,  that  emphasizes  the  pecu- 
liarities of  his  conduct. 

The  prevailing  type  of  delusion  is  that  of  grand- 
eur, which  is  so  prominent  and  constant  an  attendant 
that,  since  the  time  of  Bayle,  it  has  been  regarded  as 
one  of  the  distinguishing  features  of  general  paresis. 
These  delusions  apply  to  extravagant  notions,  relat- 

4  41 


42  SYMPTOMS    OF    GENERAL    PARESIS. 

ing  to  self-importance,  strength,  or  wealth.  They  do 
not,  at  this  time,  always  exceed  the  limits  of  possi- 
bility, but  when  within  reason  the}'  are  tinged  with 
the  bright  hues  of  exaltation.  Vain  and  confident, 
the  patient  is  boastfully  talkative  of  the  objects  of  his 
interest;  perhaps  he  may  recount  in  exaggerated 
statements  his  past  achievements,  which  may  be 
partially  based  on  facts;  or  he  builds  castles  of  his 
future  projects. 

The  sense  of  well-being  and  the  spirit  of  restless- 
ness that  it  engenders,  are  more  pronounced  than  in 
the  initial  stage  and  pertain  chiefly  to  those  interests 
in  his  life  toward  which  the  patient's  attention  may 
be  most  strongly  drawn.  Generall}',  and  in  varying 
degree,  it  is  shown  in  an  exaggerated  estimate  of  his 
own  strength,  of  his  worldly  possessions,  and  of  his 
social  and  political  status.  He  renders  himself  an 
object  of  curiosity,  and  too  often  of  mirth,  by  his 
boastful  talk  of  his  extravagant  inventions,  plans  or 
investments;  by  too  great  laudation  of  his  wife  and 
family,  or  of  some  other  near  object  of  his  affection; 
and  by  an  exalted  view  of  his  own  attainments,  or  of 
his  wonderful  intellectual  and  ph3'sical  powers.  Con- 
jointly with  sensuality  there  is  an  intense  vein  of  re- 
ligiosity; his  S3'mpathies  are  keenly  excited  for  the 
welfare  of  his  fellow-beings  and  he  is  led  into  phil- 
anthropic enterprises,  which  have  for  their  end  the 
regeneration  of  the  world. 

He  uniformly  expresses  himself  as  being  in  the 
best  of  spirits  and  health;  and  at  no  time  in  his  life 
were  his  aflairs  and  surroundings  so  much  to  his 
taste,  nor  does  he  remember  ever  to  have  felt  so  well. 

In  his  emotional  state  of  gaiety  and  recklessness, 
his  symptoms  are  much  the  same  as  those  of  mild 
simple  mania,  but  the  enfeebled  character  of  the 
mind  changes  the  general  aspect  of  the  case.     He 


Hate  U, 


FIRST  STAGE  OF  GENERAL  PARESIS. 


FIRST    STAGE.  43 

ma}^  be  irritable  and  at  times  roused  to  violence,  but 
he  can  easily  be  turned  from  his  purpose  and  calmed 
into  good-natured  compliance.  To  illustrate :  Patient, 
age  60,  was  admitted  as  a  criminal.  He  passed  a 
profligate  woman  in  the  public  park  and,  with  a 
weapon  in  his  hand,  killed  her  on  a  sudden  impulse. 
When  questioned  about  it,  some  weeks  after,  he  re- 
plied with  a  smile  of  self-complacency,  "Yes,  I  killed 
300  of  them"  (Campbell  Clark). 

There  is  now  a  persistent  tendency  to  appropriate 
articles  that  he  can  purloin,  an  increased  tendency  of 
the  moral  perversion  that  is  early  seen  in  the  pro- 
dromal stage.  For  the  same  reason,  i.  e.,  mental 
enfeeblement,  "the  patient  bears  no  malice,  is  not 
revengeful,  is  usually  generous,  facile  and  easily 
imposed  upon." 

Maniacal  excitement,  as  we  have  seen,  is  some- 
times the  form  of  onset  of  this  stage.  The  .excite- 
ment may  reach  the  degree  of  acute  delirium,  but- 
this  form  is  not  met  so  often  at  the  present  day  as 
it  was  customary  to  see  it  twenty-five  years  ago. 
After  a  variable  time  the  acute  symptoms  may  sub- 
side, leaving  the  patient  in  a  comparatively  rational 
state.  In  due  course  of  the  disease  there  is  a  return 
of  the  delirium,  followed  again  by  a  partial  subsi- 
dence oi  the  acute  explosion.  There  may  be  several 
exacerbations  of  this  character  during  this  stage,  leav- 
ing the  mind  each  time  more  clouded. 

The  insanity  of  this  stage  more  rarely  may  take 
the  form  of  melancholia  with  hallucinations,  result- 
ing in  refusal  of  food,  and  with  delusions  of  persecu- 
tion; or  the  type  may  be  a  stuporous  form.  There 
is  a  type,  termed  the  hypochondriacal,  in  which  the 
delusions,  instead  of  being  grandiose,  are  marked  by 
the  opposite  extreme.  This  condition  has  been  called 
micromania,  in  contradistinction  to  megalomania,  a 


44  SYMPTOMS    OF    GENERAL    PARESIS. 

state  of  delusive  grandeur.  The  delusions  of  the  for- 
mer class  are  as  absurd,  extravagant,  unstable  and 
unsystematized  as  those  of  expansion.  The  patient 
who  was  the  emperor  of  the  world  one  day  is  the 
poorest  beggar  the  next;  the  creator  of  the  universe 
yesterday  is  thrown  into  the  deepest  pit  of  perdition 
to-day;  and  another  who  had  the  best  brains,  a  stom- 
ach that  could  accommodate  tons  of  the  rarest  deli- 
cacies, and  boasted  of  having  a  most  powerful  body, 
wakes  up  in  the  morning  to  the  discovery  that  his 
brains  are  running  out,  and  that  his  stomach  is  gnawed 
away  by  wild  beasts  (Spitzka). 

Medico-legall}',  the  question  of  testamentary  ca- 
pacity is  one  that  is  often  involved  when  a  paretic 
attempts  to  make  a  valid  will.  Where  manifest  injus- 
tice, under  the  will,  has  been  done,  there  should  not 
be  much  difficulty  in  upsetting  it.  It  is  not  uncom- 
mon, owing  to  perversion  and  mental  enfeeblement, 
that  a  "disposing  mind"  is  absent,  as  manifested  by 
an  incapacity  of  the  testator  "to  understand  substan- 
tially the  state  of  his  family  and  of  his  affairs;  the  dis- 
position of  his  property  as  made  by  the  will;  and  to 
intend  to  make  such  disposition."  There  is,  further, 
a  strong  tendency  in  the  pliant  attitude  of  the  paretic 
to  a  weak  3-ielding  to  undue  influence.  One  could 
seldom  lind,  even  in  the  contiding  docility  of  senile 
dementia,  a  more  subservient  trust  than  these  cases 
often  exhibit  toward  the  influences  that  surround 
them. 

First  Stage.  {^Second  Period.^  Physical  Symp- 
toms.— The  general  health  of  the  patient  is  usually 
very  good.  As  one  mildly  exhilarated  with  liquor, 
he  feels  well  and  vigorous,  because  his  subjective 
feelings  are  blunted.  In  this  cheerful  frame  of  mind, 
free  from  care  and  anxiety,  all  of  his  bodil}'  functions 
are  performed  normally;   he  is  in  the  enjoyment  of  a 


FIRST    STAGE.  45 

good  appetite  and  of  restful  sleep  at  night.  But  in 
consequence  of  a  restless  spirit  which  induces  to  great 
activity  during  his  waking  hours,  the  patient  is  liable 
to  lose  flesh,  and  to  appear  worn  and  fatigued.  Some 
of  the  vaso-motor  disorders  and  sensory  symptoms, 
observed  in  the  initial  period,  may  occur,  from  time 
to  time,  in  certain  cases,  also,  in  this  stage. 

The  diagnostic  physical  symptoms  are  to  be  sought 
chiefly  in  the  defects  of  speech,  pupillary  anomalies 
and  tremor. 

In  the  beginning  of  this  stage  there  is  little  in  the 
speech  that  is  noticeable  to  the  untrained  eye  or  ear. 
The  defect  consists  in  the  slow,  slightly  labored  enun- 
ciation, as  though  the  patient  were  speaking  with  pre- 
cision; or  sometimes  there  is  a  lack  of  promptness  in 
speech,  or  an  occasional  eflbrt  to  enunciate  a  word. 
This  is  followed  in  time  by  a  blurring  of  consonants, 
and  a  slight  thickening  of  the  speech.  The  patient 
is  able  to  control  individual  movements  of  the  parts 
of  the  organs  of  speech,  but  he  is  not  able  to  coordi- 
nate them  sufficiently  to  produce  the  usual  pronun- 
ciation. There  is  added  to  this  a  certain  incoherence 
of  ideas,  due  to  the  failure  of  the  power  of  attention. 
At  first  the  hesitancy  of  speech  is  but  occasional. 
There  may  be  only  a  slight  impediment,  perhaps, 
when  the  patient  is  tired,  regaining  control  quickly; 
or  by  excitement  the  disorder  may  be  exaggerated 
for  the  time,  but  he  soon  recovers  his  normal  enun- 
ciation. But  usually  in  the  latter  part  of  this  stage 
the  difficulty  of  speech  becomes  more  noticeable  and 
fair  control  of  the  muscles  involved  cannot  be  relied 
upon. 

The  pupils  are  often  unequal,  or  the  inequality'may 
not  be  constant  but  only  occur  at  times.  In  other 
cases  they  are  found  contracted;  often  more  or  less 
sluggish  to  light.     They  may  be  irregular_in_shape, 


46  SYMPTOMS    OF    GENERAL    PARESIS. 

one  or  both;  and  this  feature  maybe  habitual,  or  only 
occasionally  present.  Dilatation  of  the  pupils  is  not 
so  common,  which  is  also  marked  b}^  irregularity. 

The  facial  expression  in  many  cases  undergoes  a 
change.  The  eyebrows  are  raised  and  when  the 
patient  is  about  to  speak  the  occipito-frontalis  is 
brought  together  with  a  tremor.  The  features  are 
generally  florid,  and  the  lines  which  give  character 
to  the  face  disappear.  In  some  cases  a  dull  leaden 
complexion  is  seen,  in  others  it  is  coarse  and  greasy. 

Sometimes  in  the  prodromal  period  before  the 
mental  signs  become  defined  there  is  an  impairment 
in  the  coordination  of  the  gait,  but  this  is  rare.  In 
this  stage,  as  a  rule,  the  gait  is  fairly  elastic  and  firm, 
although  there  is  some  ataxy,  which  ma}'  be  detected 
in  the  uncertaint}'  in  turning  round  quickly  and  even 
with  slight  swa3'ing.  Going  up  and  down  stairs  is 
sometimes  accomplished  with  difficulty  and  tripping 
over  uneven  surfaces  is  often  noticed. 

Tremor  is  another  prominent  symptom  in  this  stage, 
which  is  seen  at  first  in  the  muscles  involved  in  speech, 
as  those  of  the  face,  lips  and  tongue,  gradually  extend- 
ing to  those  of  the  hands  and  limbs.  Occupations 
which  require  delicate  adjustment  and  control  of  the 
fingers  are  early  affected,  although  the  handwriting 
remains  comparatively  steady  and  natural  throughout 
this  stage. 

A    CASE    OF    GENERAL    PARESIS    IN    THE    FIRST    STAGE. 

F,  Y.,  strong,  35  yrs.  old,  without  any  known  hereditary 
predisposition  to  insanity  ;  previously  enjoyed  good  health. 
His  temperament  is  sanguine,  diathesis  neuro-arthritic,  and 
his  disposition  frank,  unsuspicious,  boastful  and  hasty. 
He  had  always  a  good  opinion  of  himself;  imaginative; 
had  a  physiological  tendency  to  exaggeration.  His  feel- 
ing of  bien-etre  was  above  the  average  ;  he  was  industrious 


FIRST    STAGE.  47 

and  at  times  worked  very  hard.  He  had  lived  well,  tak- 
ing not  a  little  of  alcoholic  stimulants  habitually ;  eating 
much,  sleeping  little ;  exceeding  greatly  in  regard  to 
sexual  intercourse.  He  had  not  had  syphilis,  and  showed 
no  signs  of  it.  In  recent  months  ' '  has  not  been  the  same  "  ; 
he  had  flying  pains  in  the  head  ;  was  a  little  forgetful ;  want- 
ing in  application  to  his  work,  and  was  irritable  at  home. 
A  month  ago  he  began  to  express  an  exaggerated  sense  of 
well-being,  so  that  a  stranger  remarked:  "  What  a  con- 
ceited fool  that  man  is  I  "  He  could  not  settle  down  to  his 
daily  work.  This  state  went  on  for  some  time  without 
awakening  suspicion  of  insanity  until  one  morning  he  an- 
nounced that  he  had  purchased  several  hundred  pounds' 
worth  of  silver  plate,  and  that  he  had  lots  of  money,  having 
a  scheme  through  which,  in  a  week,  he  could  be  worth 
hundreds  of  thousands  of  pounds.  His  wife  found  that  he 
had  been  buying  many  useless  things,  besides  the  plate  ; 
he  had  four  gold  pencil  cases,  as  presents  for  people  whom 
he  did  not  know.  He  was  sent  off  to  the  country ;  rest- 
lessness increased  ;  constant  talking  ;  almost  complete  sleep- 
lessness ;  his  boastfulness  became,  in  three  or  four  days, 
exaggerated  delusions.  He  said  that  he  could  lift  i,ooo 
pounds,  that  he  was  the  best  rider,  swimmer  and  jumper  in 
the  world ;  he  wanted  to  buy  every  farmer's  horse  that  he 
met,  never  offering  less  than  lOO  pounds  and  would  bid 
another  lOO,  if  his  first  offer  was  refused.  He  wrote  to  the 
Queen  and  other  notables,  offering  his  services  to  make 
their  fortunes,  and  asking  them  to  dinner.  In  writing,  he 
omitted  many  single  words.  A  few  days  later,  he  was  so 
impatient  of  contradiction  that  he  struck  his  wife,  but  he  was 
usually  easily  managed.  He  was  sent  to  an  asylum,  offering 
to  buy  it  for£ioo,ooo  and  later, for£i, 000,000.  On  hearing 
that  they  could  not  get  along  without  it,  he  said  he  would 
build  another,  the  most  magnificent  in  the  world,  endow  it 
with  a  million  a  year,  make  me  physician-in-chief,  and  get 
the  Queen  to  make  me  a  baronet,  and  give  me  a  uniform 
made  of  gold  cloth.  He  has  been  sleepless,  destructive 
of  clothing,  unclean,  in  constant  motion,  facile  in  some 
respects,  but  violent  when  his  commands  were  not  instantly 


48  SYMPTOMS    OF    GENERAL    PARESIS. 

obeyed.  He  was  not  surprised  at  being  brought  to  the 
asylum,  and  felt  no  resentment  towards  those  who  brought 
him.  He  walks  with  a  quick  step,  talks  rather  fast,  and  has 
the  least  slurring  towards  the  ends  of  long  sentences  and 
in  articulating  long  words  with  many  oft-repeated  con- 
sonants. There  is  fibrillar  twitching  in  the  small  muscles 
of  the  lips,  and  around  the  eyes,  especially  when  he  breaks 
into  a  smile.  His  tongue  quivers  in  lines  on  its  surface, 
single  strands  of  muscles  being  affected.  His  pupils  are 
contracted,  irregular  in  outline,  right  larger  than  the  left, 
which  is  insensitive  to  light.  Sometimes  the  right  is  small 
and  insensitive  to  light,  or  large  and  insensitive  to  light. 
The  expression  of  the  eyes  is  feverish  and  strange ;  skin 
moist;  temperature  99.6*^,  rising  to  over  100°  at  night ;  pulse 
full  and  hard.  He  cannot  sit  still ;  has  an  abnormal  gene- 
ration of  energy  ;  common  sensation  markedly  diminished  ; 
sense  of  smell  somewhat  weakened  ;  tastes  imperfectly  ;  he 
calls  blue  wool  red.  His  patellar,  spinal  and  skin  reflexes 
are  very  acute.  He  is  very  easily  led  from  one  subject  to 
another;  he  is  very  irritable  on  contradiction.  A  general 
paretic  will  not  yield  to  a  show  of  force.  He  could  walk 
along  a  narrow  board  on  the  floor  all  right,  but  when  sud- 
denlv  told  to  turn  around,  he  could  not  do  so  sharply,  but 
took  a  circle  and  that  waveringly.  (Abstract,  Clouston, 
Mental  Disease,  p.  379.) 

A    CASE    OF    GENERAL    PARESIS    OF    THE    MANIACAL    FORM, 
A    REMISSION    FOLLOWING    TREATMENT. 

B.,  male,  married,  ast.  35,  admitted  after  an  illness 
stated  to  be  of  only  fourteen  days'  duration.  Previous 
history :  Entered  army  thirteen  years  ago.  Before  this 
he  had  contracted  syphilis  and  was  supposedly  cured. 
He  had  several  attacks  of  fever,  and  later  unmistakable 
signs  of  secondary  syphilis ;  but  recovered,  married,  be- 
came an  accountant  and  cashier,  he  being  without  the  neces- 
sary education  for  the  position,  consequently  broke  down, 
due  to  the  mental  strain,  while  his  figures  were  found  to  be 
in  confusion.  On  admission,  he  was  maniacal,  impulsive, 
violent  and  very  strong  ;  he  was  very  loquacious,  incoherent 


FIRST    STAGE.  49 

and  exalted;  he  said  he  was  second  son  of  God,  very 
wealthy,  etc.  ;  he  offered  gifts  of  £20,000,  etc.  He  suffered 
much  from  insomnia,  pupils  normal,  no  tremor  of  lips  or 
face ;  no  elevation  of  temperature,  organs  healthy.  The 
first  development  of  the  disease  occurred  at  a  dinner  at  his 
house,  where  he  had  been  unusually  voluble,  and  when 
his  wife  remonstrated  with  him,  he  burst  into  tears.  Two 
weeks  after  admission  he  began  to  wet  his  bed,  his  mania 
frequently  flared  out,  notwithstanding  doses  of  bromide, 
throwing  knives  at  those  near  him,  even  when  unprovoked  ; 
exaltation  advanced  ;  recognized  and  deplored  his  loss  of 
memory.  Under  treatment  (calabar  bean  gr.  one  sixth, 
iodide  of  potassium,  ammonia-citrate  of  iron,  hydrobromic 
acid)  he  improved  very  much.  Ten  weeks  after  com- 
mencement, the  treatment  was  stopped  and  he  was  pre- 
maturely allowed  to  visit  his  friends,  but  returned  in  seven 
days  complaining  of  headache  and  insomnia.  These  were 
relieved  by  quiet  and  h3'drobromic  acid  ;  he  was  sent  to  sea- 
side house  for  six  weeks  and  then  discharged  six  months 
after  the  development  of  the  disease.  In  ten  weeks,  he 
wrote  a  letter  free  from  the  various  peculiarities  of  style 
usual  in  general  paretics,  but  saying  that  his  legs  were  very 
unsteady,  so  that  while  he  could  play  tennis,  the  fact  of 
knocking  one  foot  against  the  other  was  sufficient  to  throw 
him  down.  His  mental  faculties  appeared  unclouded, 
though  they  were  not  exposed  to  any  strain.  He  mingled 
in  society  and  held  his  own,  but  before  long  the  disease 
returned  and  he  died.  (Abstract,  Fox,  B.  B.,  Journal  of 
Mental  Sciences,  Vol.  73,  p.  389.) 

DELUSIONS    OF    GRANDEUR. 

A  gentleman  said  he  could  easily  run  six  hundred  miles 
in  a  minute;  that  he  could  fly;  that  by  cutting  out  his 
entrails,  he  should  make  himself  so  light  that  he  could 
jump  a  mile,  and  by  constant  springing  could  mount  higher 
and  higher;  that  he  could  speak  all  the  languages.  He 
mixed  all  his  food  together  on  a  plate,  which  he  called  the 
kosmos  that  would  make  him  strong,  etc.  (Abstract,  San- 
key,  Lectures  on  Mental  Diseases,  p.  262.) 


50  SYMPTOMS    OF    GENERAL    PARESIS. 

DELUSIONS    OF    GRANDEUR. 

One  patient  proposes  to  buy  up  all  the  water-power  in 
the  United  States,  and  let  it  out  to  applicants  at  high  prices. 
He  made  a  table  showing,  in  his  opinion,  where  the  power 
is,  its  capacity,  the  price  for  which  it  can  be  obtained,  and 
an  estimate  for  which  it  can  be  leased.  The  profits  amount 
to  over  a  hundred  millions  a  month.  Another  patient  was 
going  into  the  shipbuilding  business,  intending  to  build 
vessels  capable  of  carr3'ing  ten  thousand  cabin-passengers 
each,  and  of  making  the  voyage  to  Europe  in  twenty-four 
hours.     (Abstract,  Hammond  on  Insanity,  p.  6oi.) 

DELUSIONS    OF    GRANDEUR. 

G.  H.  believed  he  had  interviews  with  the  Almighty 
and  the  Holy  Ghost,  that  he  had  £40,000  in  bank,  that  he 
was  kincT  of  England  and  therefore  accused  every  one  of 
not  paying  him  proper  respect ;  he  promised  to  clothe  the 
other  patients  in  armor  of  gold  and  said  the  buttons  in 
their  clothing  were  made  of  his  gold.  (Abstract,  Bucknill 
&  Tuke,  Manual  of  Insanity,  p.  313.) 

A    W^OMAN    WITH    DELUSIONS    OF    GRANDEUR. 

A  woman  insisted  that  she  was  the  wife  of  the  Saviour ; 
also  of  a  certain  duke,  that  she  had  other  husbands,  more 
than  a  million;  that  God  gave  her  many  rare  jewels;  that 
she  had  twenty  Koh-i-noors.  She  exhibited  also  in  these 
notions  a  great  deal  of  erotic  tendency.  (Abstract,  San- 
key,  op.  cit.,  p.  262.) 

EXTRACTS    FROM    THE    LETTERS    OF    A    PARETIC,    THE 
EROTIC    PASSAGES    BEING    OMITTED. 

My  own  darling  and  adored  wife  Mary  :  My  heart  calls 
you  to  come  to  it.  Your  dear  angel  presence  only  can 
satisfy  its  constant  longing.  I  count  the  hours  in  fear  to 
your  coming ;  a  thousand  doubts  besiege  me  night  and 
day.  For  me  there  is  no  light  nor  life,  nor  cheer,  while 
thou  remainest  away.     Thou  art  my  Peace,  my  Hope,  my 


FIRST    STAGE.  5 1 

only  Fortune  and  the  shining  angel  of  my  soul.  Oh  come 
to  me,  for  you,  alone,  are  mine  and  you  only  can  still  my 
doubts  and  fears.  My  blessed  and  lovely  sweetheart 
wife,  Mary.  You  must  come  to  me  or  my  heart  will  break 
with  grief.  Come  and  we  will  celebrate  our  reunion  and 
my  perfect  health,  my  love  and  affection,  free  from  care 
for  a  week.  You  are  my  Queen,  all  I  have  is  yours,  my 
heart  and  my  purse.  I  have  never  destroyed  a  single 
letter  of  yours.  I  have  preserved  them  all  because  my 
love  for  you  has  been  so  deep  and  tender,  so  strong  and 
lofty,  so  ardent  and  so  sacred  that  I  would  have  deemed 
myself  guilty  of  a  sacriligious  act  to  destroy  even  one  of 
them.  I  have  them  all  preserved  and  you  and  I  will  read 
them  over  together  some  time.  I  am  sure  it  will  recall 
happy  hours  and  delightful  memories  of  our  lives  in  the 
past.  Let  us  keep  on  being  happy  together,  for  I  never 
was,  and  never  can  be,  happy  when  I  am  away  from  your 
easeful  and  nepenthe  presence.  In  your  charming  society 
I  often  think  I  am  the  one  man  who  is  renowned  because 
I  really  and  truly  love  and  am  loved  by  you.  Ever  since 
your  dear  kind,  sweet,  speaking  eyes  spoke  love  into  my 
heart  you  have  been  the  bright  and  shining  angel  of  my 
dreams,  as  you  have  been  the  sole  Queen  of  my  loving 
heart  and  of  my  delightful  and  happy  home.  My  darling 
and  revered  wife,  I  so  long  to  see  you  that  I  do  believe  I'll 
go  crazy  unless  you  come.  I  am  constantly  thinking  and 
thinking  of  you  ;  I  never  cease  to  think  of  you  and  to 
bless  your  dear  memory.  You  are  the  most  blessed  wife 
in  all  the  wide,  wide  world.  I  will  be,  oh  so  happy  when 
I  can  get  my  arms  around  you.  I  know  of  no  blissful 
feeling  than  to  be  once  again  in  your  sweet,  beautiful, 
gentle,  tender  and  blessed  presence.  I  very  clearly 
see  that  you  are  the  gentlest  and  sweetest  and  the 
most  sensible  lady  in  the  wide  world.  I  love  you  and  my 
dear  little  boy,  J.  W.  W.,  esquire,  with  all  the  love,  pas- 
sion and  vehemence  of  my  heart.  And  I  honor,  I  dearly 
love  and  highly  respect  the  dignified,  serene,  grand,  noble, 
magnificent  and  queenly  lady,  my  dear  and  adored  and 
blessed  grandma,  X.  Y.  M.     I  hope  and  have  prayed  to 


52  SYMPTOMS    OF    GENERAL    PARESIS. 

Almighty  God  to  allow  and  save  my  dear  grandma  from 
death  and  sickness. 

I  realize  that  my  sweet,  darling  wife,  Mary,  will  very 
soon  come  to  see  me.  There  is  no  such  other  inspiration 
as  is  the  inspiration  of  hope.  Hope  illumines  our  pathway 
through  the  rough  places  of  earth,  etc.  I  hope  to  be  home 
very  soon.  I  send  to  my  sweet  wife,  to  my  dear  little  J. 
W.  W.,  esquire,  and  to  my  dear  and  good  grandma,  X. 
Y.  M.,  all  the  great  love  of  my  heart  and  to  you  my  sweet 
angel  wife,  Mary,  I  send  ten  thousand  kisses. 

Again  he  says  :  I  am  going  home  to  love  my  heart's 
only  darling,  my  sweet,  lovely  angel  wife,  Mary,  and  to 
enjoy  the  charming  and  beautiful  society  and  comradeship 
of  the  woman  I  chose  for  my  bride  and  wife  more  than 
twenty  years  ago.  How  well  I  remember  the  evening,  the 
hallowed  and  blessed  evening,  when  I  asked  you  with  my 
arms  around  you  to  be  my  wife  and  how  you  then  raised 
^j^our  dark,  beautiful,  speaking  eyes  timidly  up  to  mine  and 
murmured  the  blessed  "yes"  and  how  then  and  in  a 
moment  our  waiting  souls  met  and  embraced  in  one  look 
of  recognition  and  bliss.  Oh,  that  blessed  word  "  yes  "  you 
gave  me  then ;  God  has  written  it  upon  my  heart  forever. 
Never,  never,  will  I  forsake  the  dear  lips  which  spoke 
that  word  nor  fail  in  all  loving  doubt  and  affection  to  my 
sweet  Mary  to  the  end  of  my  life.  Life  is  like  a  bright 
river  when  it  springs  from  the  fresh  fountains  of  the  heart. 
It  flows  on  beautifully,  forever  and  ever  widening  until  it 
reaches  the  ocean  of  eternity  and  happiness,  etc.,  etc. 

A  LETTER  OF  A  PARETIC  IN  THE  EXALTED  STAGE. 

"  Countess  of  Elgin  and  Durham  "  (but  really  to  Queen 
Victoria). 

" House,  Royal  National  Lunatic  Asylum." 

My  dear  wife  : — I  am  up  to  the  mark  and  hope  that  your 
S3"stem  is  up  to  the  scratch. 

Has  John  Brown  undergone  any  form  of  cremation?     I 

am    glad    to    him    adopting    my    style   of  shepherd 

checked  trousers.  I  hope  both  queens  are  well,  with 
Princess  Louise,  Princess  Beatrice, that  I  will  give 


FIRST    STAGE.  53 

them  all  that  is  necessary  in  this  world  and  the  world  to 
come.  Compts.  to  darling  "Eugene."  Your  affct.  hus- 
band.    (Abstract,  Clouston,  of.  cit.,  p.  383.) 


A  PATIENT  PRINTED  THE  PROSPECTUS  OF  A  COMPANY  HE 

WAS  ABOUT  TO  ORGANIZE,  TO  ACQUIRE  FROM  THE 

PRINCIPAL  GOVERNMENTS  THE  EXCLUSIVE  RIGHT 

TO  MANUFACTURE  INDIA-RUBBER  RATTLES. 

THE  FOLLOWING  IS  THE  COPY  OF  A 

FEW  PARAGRAPHS  FROM  HIS 

DOCUMENT. 

Everybody,  from  the  infant  in  arms  to  the  decrepit  old 
man,  likes  to  make  a  noise  in  the  world.  The  noise  that 
should  be  made  is  a  gentle,  undulating,  penetrating,  but 
not  irritating  jingle.  Experiments  show  that  such  a  noise 
has  the  soothing  influence  of  opium  and  chloral  without 
their  danger.  I  have  established  the  fact,  after  expend- 
ing $10,000,000,  that  the  best  rattles  for  the  purpose  are 
made  by  a  silver  bell  enclosed  in  a  hollow  india-rubber 
sphere,  to  which  a  handle  is  affixed.  Thus  constructed, 
the  rattle  in  the  hands  of  either  infancy  or  old  age,  the 
youth  or  adult,  the  maiden  or  her  lover,  the  old  maid  or  the 
bachelor,  the  widow  or  the  widower,  the  barbarian  or  the 
civilized  man,  the  king  or  the  subject,  the  gentleman  or 
the  ruffian,  the  honest  man  or  the  thief,  the  Christian  or 
the  Jew,  the  saint  or  the  sinner,  the  gentleman  or  the 
blackguard,  the  moral  man  or  the  hardened  wretch  who 
panders  to  the  most  depraved  appetites  of  the  scoundrels, 
who  fatten  on  the  life  blood  of  the  people — all,  all,  must 
have  the  india-rubber,  health-giving  and  mind-soothing 
rattle. 

The  undersigned  has  devoted  over  two  hundred  and 
fifty  years,  both  in  this  world  and  in  a  former  state  of 
existence,  to  the  investigation  of  the  properties  of  india- 
rubber  and  silver.  He  has  ascertained,  after  many  failures, 
and  the  expenditure  of  over  $20,000,000,  that  the}-  exercise 
health  and  life-giving  properties  to  all  men.  Rattle  and 
you  will  live,  rattle  and  you  will  be  happ}',  rattle  and  you 


54  SYMPTOMS    OF    GENERAL    PARESIS. 

will  prosper,  rattle  and  you  will  be  successful,  rattle  and 
you  will  be  able  to  procreate  more  children  than  the  uni- 
verse can  contain. 

A  company  must  be  organized  to  carry  out  the  bene- 
ficent objects  which  the  undersigned  has  in  view.  No 
subscriptions  in  money  are  required,  as  he  has  taken  all 
the  stock,  to  the  extent  of  $1,000,000,000.  He  is  now 
contracting  for  all  the  rubber  the  world  can  produce,  and 
is  about  bu^'ing  two  hundred  of  the  richest  silver  mines  in 
the  world.  Every  man,  woman  and  child  on  the  face  of 
the  earth  will  require  several  rattles,  for,  by  varying  the 
tone  of  the  bell,  different  properties  are  given  to  the  rattle, 
and  hence  the  same  rattle  will  not  do  for  every  person  or  for 
ever}'^  purpose.  Come  up,  therefore,  and  aid  in  this  grand 
undertaking  in  which  profits  of  thousands  of  millions  of 
dollars  will  be  made  every  year,  and  the  human  race 
rendered  happy.     (Abstract,  Hammond,  o^.  cii.,  p.  601.) 


CHAPTER  V. 

SYMPTOMS    OF    GENERAL    PARESIS    {continued). 

Second  Stage.  {Third Period^  Mental  Symptoms. 
— The  failure  of  mind  is  most  apparent  in  this  stage, 
and  the  patient  is  no  longer  able  to  form  new  ideas, 
but  gives  expression  to  the  old  delusions,  in  a  de- 
sultory, stupid  manner,  characterized  by  increasing 
dementia.  They  are  but  the  automatic  semblance  of 
grandiose  ideas,  conceived  when  the  memory  and  the 
imagination  had  not  lost  their  strength  and  scope. 

The  conduct  of  the  patient  assumes  the  uncertain 
and  foolish  actions  of  a  child;  and  there  is  no  extrava- 
gance too  bold,  nor  any  absurdity  too  grotesque,  to 
which  his  attention  may  not  be  invited.  He  becomes 
less  and  less  trustworthy  and  responsible,  without 
limit  to  the  nonsensical  lengths  to  which  his  caprice 
may  carry  him.  He  loses  all  appreciation  of  his  sur- 
roundings, and  all  sense  of  the  proprieties  or  of  shame. 
He  gathers  together  in  his  pockets  rubbish  of  every 
description,  to  which  he  attaches  much  value,  being 
able  no  longer  to  discriminate  between  what  is  his 
own  and  what  is  the  belongings  or  the  rights  of  others. 

While  careless  and  neglectful  of  others,  he  fails  to 
discern  his  own  interests,  and  in  the  matter  of  per- 
sonal appearance  he  is  not  only  thoughtless,  but  falls 
into  the  slovenly  habits  that  at  a  later  period  become 
faulty  and  unclean  to  an  extreme  degree. 

At  this  stage  the  appetite  is  apt  to  be  voracious, 
and  in  eating  he  displays  the  instincts  that  belong  to 
an  animal,  rather  than  to  the  human  kind.  Forgetful 
often  of  the  amount  of  food  partaken,  he  is  ever  ready 

55 


56  SYMPTOMS    OF    GENERAL    PARESIS. 

to  indulge,  until  he  reaches  the  excesses  of  the  glut- 
ton. In  the  latter  part  of  this  stage,  the  rumination 
spoken  of  by  writers,  takes  place  in  long  and  distress- 
ing periods  of  grinding  of  the  teeth. 

Second  Stage.  { Third  Period.)  Physical  Symp- 
toms.— Concurrently  with  the  increased  mental  im- 
pairment there  is  a  deepening  of  the  physical  symp- 
toms, denoted  by  graver  nervous  disturbances.  In 
the  tirst  stage  the  patient  usually  loses  flesh,  but  in 
this  stage  he  takes  on  flesh  conspicuously  and  becomes 
stout  and  flabby. 

A  distinctly  impaired  articulation  is  now  a  marked 
feature.  The  character  of  the  speech  has  often  been 
compared  to  that  of  a  drunken  man.  The  patient 
seems  to  stumble  over  his  words,  and  at  the  same 
time  his  enunciation  is  halting  and  blurred.  The 
labials  and  Unguals  prove  most  troublesome,  as  may 
be  seen  from  the  attempted  pronunciation  of  such 
words  as  "perambulator,"  "artillery,"  "immovability," 
"  cavalry  brigade,"  etc.,  in  which  the  consonants  or 
entire  syllables  may  be  omitted,  reduplicated,  or  even 
misplaced.  Alliterative  lines  are  for  the  most  part 
impossible  to  paretics,  but  as  they  are  troublesome  to 
many  people  in  normal  condition,  they  are  scarcely  a 
test.  At  this  stage  words  may  be  uttered  with  an 
evident  propelling  force,  or  the  speech  may  be  slow 
and  drawling;  there  is  a  frequent  omission  of  words, 
an  entanglement  of  thought,  a  forgetting  of  the  idea 
when  half  expressed. 

The  tongue  can  only  be  thrust  out  in  a  jerk}-  man- 
ner with  great  eflbrt,  and  fibrillar  movements  on 
each  side  of  the  mesial  line  may  be  distinctly  seen. 
The  spasmodic  twitchings  of  the  muscles  about  the 
mouth,  and  especially  those  of  the  upper  lip  and  of 
the  forehead,  occurring  with  the  attempted  utterance 
of  a  sentence  or  of  a  diflficult  word,  give  an  appear- 


PUte  III. 


SECOND  STAGE  OF  GENERAL  PARESIS. 


SECOND    STAGE.  57 

ance  to  the  face  at  times  that  is  misleading.  The 
patient  attempting  thus  to  speak,  appears  to  be  break- 
ing into  a  violent  fit  of  weeping  (Bucknill). 

Excitement  adds  to  the  disorder.  Words  seem  to 
struggle  for  expression,  ideas  become  confused  and 
as  the  affection  increases  the  patient  may  become 
unintelligible  in  his  gibberings,  or  he  may  express, 
with  evident  delight,  new  ideas,  and  use  newly  coined 
words,  expressing  all  in  a  spasmodic  hurr3^  After 
such  outbursts  the  speech  is  more  halting  than 
before. 

The  speech  is  slow  and  drawling  from  the  cerebral 
lesions  and  stammering  or  tremulous  from  the  bulbar: 
"  cortical  and  mental  failure  are  now  complicated  with 
ataxia  and  with  paretic  defects  of  articulation." 

The  pupils  are  now  generally  sluggish  in  reaction, 
both  to  light  and  accommodation;  they  are  also  irreg- 
ular in  shape  and  unequal  in  size.  Another  anomaly, 
one  is  often  contracted  and  the  other  dilated,  while 
the  relative  size  and  shape  of  the  pupils  will  be  found 
very  perceptibly  to  change  from  time  to  time.  The 
underlying  pathology  of  this  condition  has  evoked 
much  discussion  in  the  past.  A  further  statement  of 
these  particulars  is  given  under  the  section  devoted 
to  eye  symptoms. 

The  features  have  undergone  still  greater  change 
than,  noticed  before,  having  become  "  fat  and  flabby," 
and  the  skin  coarse  and  unctuous.  The  expression 
has  become  dull  and  stolid  and  some  refer  to  the  con- 
tradictory feelings  which  are  falsely  portrayed;  one 
portion  of  the  face  giving  evidence  of  an  emotion 
which  the  other  does  not  reveal. 

The  body  settles  upon  itself,  as  seen  in  advanced 
age,  with  much  stoop  to  the  shoulders.  The  trunk 
at  times  is  bent  to  one  side,  which  may  be  temporary 
or  persistent. 


58  SYMPTOMS    OF    GENERAL    PARESIS. 

Tremuloiisness  of  the  muscles  is  a  prominent  symp- 
tom. Besides  the  difficulty  of  speech  due  to  this  cause 
there  is  first  spasmodic  twitchings  of  the  lips  and  face, 
which  extends  to  other  groups  of  muscles,  controlling 
the  movements  of  the  hands  and  limbs.  Combined 
with  incoordination  it  soon  becomes  difficult  for  the 
patient  to  direct  his  hands  and  lingers  in  the  perform- 
ance of  the  simplest  movements,  as  t3'ing  shoes  or 
buttoning  and  unbuttoning  clothing.  Shortly  the 
larger  and  coarser  groups  of  muscles  become  in- 
volved so  that  the  gait  gets  to  be  clumsily  performed. 
At  first  the  patient  walks  slowly  with  care,  planting 
the  feet  wide  apart;  there  is  swerving  at  times  and  the 
line  of  progress  may  even  be  zigzag.  He  takes  short 
steps,  a  shuffling,  uncertain  gait,  being  liable  to  trip 
when  the  surface  is  uneven,  or  fall  when  attempting 
to  hurry  or  turn.  Towards  the  end  of  the  stage  the 
commoner  habits — walking,  talking,  writing  and  eat- 
ing solid  food  —  are  accomplished  with  more  and 
more  difficult}'  on  account  of  the  muscular  weakness, 
tremulousness  and  incoordination;  at  last  these  habits 
become  abolished. 

It  is  at  this  stage  that  congestive  attacks,  usually  as 
epileptiform  seizures,  are  common.  On  account  of 
other  diagnostic  symptoms,  they  are  not  longer  of 
much  value  as  confirmatory  of  the  disease,  as  they 
are  in  the  earlier  stage,  but  they  are  now  followed  by 
marked  deterioration  in  both  the  mental  and  physical 
phases  of  the  alTection.  In  some  cases  the  seizures 
may  take  the  form  of  an  apoplectic  attack,  succeeded 
b}'  temporary  loss  of  power  in  one  limb,  or  of  one 
side.  These  cerebral  seizures,  which  will  be  treated 
more  at  length  under  another  division,  vary  much  in 
character  and  intensity,  being  at  times  so  slight  as  to 
attract  but  small  attention,  at  other  times  so  severe  as 
to  imply  the  greatest  gravity. 


SECOND    STAGE.  59 

ILLUSTRATIVE    CASES    IN    THE    SECOND    STAGE. 

R.  J.  B.,  admitted  to  Philadelphia  Hospital  February, 
1895,  get.  51,  salesman.  Family  history  negative  as  to 
mental  and  nervous  diseases.  Patient  had  a  severe  blow 
on  the  back  of  the  head  in  1876,  which  left  him  with  a 
headache  for  several  3^ears.  He  had  been  a  hard  drinker. 
In  1887,  after  a  drinking  bout,  his  friends  say  that  he 
"  acted  crazy  "  for  a  week  or  ten  days.  Recently,  he  has 
been  indifferent  to  the  wants  of  his  family  ;  developed  de- 
lusions as  to  wealth,  money-getting,  etc.  ;  pawned  any- 
thing he  could  get  at  home ;  said  he  stopped  runaway 
horses,  etc.  ;  gave  checks ;  signed  his  mother's  name  to 
checks  on  a  bank,  where  some  years  ago  he  had  an  ac- 
count ;  abandoned  his  religious  belief  and  joined  the  new 
order  of  the  "third  Christians."  On  admission,  when 
asked  what  was  his  business,  he  replied :  "I  have  been  a 
manufacturer  of  the  first  character  of  ladies'  shoes  for 
twenty-five  years.  Our  firm  is  a  queer  combination,  me  a 
Friend,  two  Jews,  and  a  Dutch  Roman  Catholic,  so  we 
never  discuss  religion.  We  do  a  business  of  $600,000  a 
year,  the  profits  being  28  to  30  per  cent.  We  make  only 
the  best  shoes,  silk  linings,  and  many  have  gold  or  silver 
buttons."  He  said  he  had  not  accumulated  much  money 
because  his  brothers  needed  so  much  of  it.  "  However,  I 
have  been  left  $6,000,000  in  the  following  way  :  In  Janu- 
ary, 1877, 1  caught  the  runaway  horses  of  a  gentleman  and 
no  doubt  saved  his  life.  He  took  my  name  and  address, 
and  four  months  ago  when  he  died  he  left  me  $3,000,000, 
and  there  was  a  codicil  which  said  that  if  not  satisfied  I 
should  ask  for  more,  and  so  I  asked  for  $6,000,000  more. 
I  also  own  two  charitable  hospitals,  which  I  have  endowed 
for  $1,000,000."  The  patient  says  that  he  was  "Governor 
of  the  State;  in  1873  Mayor;  at  the  present  time  he  is 
United  States  Senator  and  has  been  recently  nominated  for 
Select  Council"  ;  that  he  has  always  had  "the  biggest  ma- 
jority of  any  one  in  this  city."  In  another  minute  he  says 
he  is  a  graduate  in  medicine  at  Harvard,  in  Berlin,  in  Paris  ; 
that  he  has  practiced  medicine  for  eighteen  years ;  that  he 
has  been  an  "  elegant  singer  and  player."     He  is  sleepy- 


6o  SYMPTOMS    OF    GENERAL    PARESIS. 

looking,  nervous  in  action,  calm  in  mind  ;  hardly  recog- 
nizes his  surroundings;  calls  the  hospital  the  "Hughes 
Academy."  He  seemed  to  believe  exactly  what  he  said. 
February  12,  1895,  his  delusions  of  grandeur  are  grow- 
ing greater;  he  sleeps  and  eats  well.  February  15,  at 
5 .45  last  evening  he  was  determined  to  leave  the  hospital  and 
broke  a  pane  of  glass  with  a  chair,  and  when  the  attend- 
ant tried  to  quiet  him  he  attacked  the  latter.  March  5, 
transferred  to  acute  ward  and  placed  in  bed  ;  he  has  been 
perfectly  tractable  and  in  one  week  was  allowed  to  get  up. 
He  now  estimates  his  wealth  at  $150,000,000,  $50,000,000 
of  which  he  made  "  in  as  many  minutes  " ;  he  is  not  cogni- 
zant of  his  surroundings  ;  shows  no  discontent.  His  face  is 
expressionless  and  pale  ;  eyes,  partial  ptosis  ;  pupils  small, 
unequal,  the  right  larger  ;  reaction  to  light  imperfect ;  ac- 
commodation normal ;  tongue  slightly  tremulous  ;  knee-jerk 
exaggerated  ;  no  ankle  clonus  ;  cremasteric  reflex  feeble  ; 
viscera  normal.  (Abstract,  Dercum,  Nervous  Diseases, 
p.  677.) 

ILLUSTRATIVE    CASE    IX    THE    SECOND    STAGE. 

F.  X.,  now  45,  a  clerk.  He  became  affected  a  year 
ago.  He  has  gone  through  a  first  stage  of  exaltation  and 
excitement,  which  for  the  past  two  months  has  been  gradu- 
ally passing  off.  He  has  lack  of  facial  expression  ;  face 
looks  fat,  heavy  and  dull  ;  even  when  he  speaks  his  fea- 
tures do  not  correspond  to  his  emotions.  He  is  flabby, 
and  has  made  up  in  fat  for  the  two  stones  (28  lbs.)  that  he 
lost  during  the  early  stage  of  the  disease.  He  has  a  con- 
tented, facile  hebetude  of  mind,  and  expresses  few  wants. 
He  says  that  he  is  quite  well,  and  that  he  can  walk,  work, 
sing  or  do  business  as  well  as  he  ever  did  ;  none  of  which 
is  true,  for  he  is  very  shaky  on  his  legs  and  cannot  walk  a 
mile.  His  handwriting  is  tremulous  ;  he  has  no  initiative 
mental  power ;  no  spontaneity  ;  and  no  power  of  volition. 
He  does  not  obtrude  his  delusions,  but  still  has  them.  His 
pupils  are  widely  dilated,  the  left  more  so  than  the 
right ;  pulse  is  68  and  easily  compressible,  his  tempera- 
ture 97°,  but  still  a  little  higher  at  night.  His  tendon 
reflex    is    dull,    also    his    spinal     reflex    functions,     and 


SECOND    STAGE.  6l 

power  of  swallowing,  a  little  impaired.  His  speech  is 
markedly  affected  now  and  the  tone  of  his  voice  quite 
changed.  He  cannot  say  such  test  words  as  "hippopota- 
mus," "  royal  artillery,"  etc.  There  are  still  some  tremb- 
lings about  his  face  as  he  speaks,  but  they  consist  in  the 
incoordination  of  whole  groups  of  facial  and  articulatory 
muscles.  He  is  ver\'  kleptomaniacal.  The  dorsum  of  his 
tongue  presents  a  general  undulatory  surface,  when  put 
out.  He  cannot  turn  round  quickly  without  risk  of  falling, 
or  stand  on  one  leg.  He  straddles  a  little  in  walking  ;  he 
is  apt  to  stumble  over  small  obstacles  ;  and  becomes  almost 
paralyzed  after  a  long  walk.  His  muscular  movements 
have  no  vigor.  His  urine  often  dribbles  away.  He  is 
occasionally  noisy  at  night  in  a  careless  way.  (Abstract, 
Clouston,  ]NIental  Diseases,  qth  ed.,  p.  384.) 

ILLUSTRATIVE    CASE    IN    THE    SECOND    STAGE. 

A  gentleman,  ast.  36,  owner  of  a  large  business ;  in 
summer  of  1897,  family  noticed  he  was  "not  quite  him- 
self " ;  a  transient  irascibility  and  tendency  to  forgetful- 
ness.  In  1898  symptoms  increased,  and  during  an  illness 
of  his  wife,  an  emotional  state  was  added  ;  next,  incom- 
plete parah'sis  of  internal  rectus  to  left  eye,  for  which 
oculist  gave  him  glasses  and  said  it  would  be  necessary 
to  have  it  cut  if  they  did  no  good.  The  patient  became 
hypochondriacal ;  he  was  sent  to  consult  a  medical  man 
of  note,  who  called  it  "  neurasthenia."  The  patient  was 
treated  accordingly  but  the  downward  course  was  more 
rapid.  In  spring  of  1899,  alarming  mental  symptoms 
supervened  and  the  case  came  to  me ;  diagnosis  of  demen- 
tia paralytica,  in  the  beginning  of  the  second  stage.  A 
few  days  later,  he  became  maniacal,  attempted  to  kill 
several  people,  and  probably  w^ould  have  succeeded,  had 
not  all  deadly  weapons  been  removed.  I  elicited  a  history 
of  syphilitic  infection  ten  3'ears  ago,  also  of  excesses  in 
alcohol.  At  first  examination,  pupils  rather  small,  and 
reacting  slowly  to  light  and  accommodation  ;  consensual 
movements  of  iris  completely  lost ;  knee-  and  wrist-jerks 
absent.     There  had  been  rheumatic  pains  for  several  years, 


62  SYMPTOMS    OF    GENERAL    PARESIS. 

and  skin  about  plantar  surface  of  feet  showed  sligbt  anes- 
thesia ;  insufficiency  of  both  internal  recti  which  dated 
from  a  few  months  before  and  a  slight  lateral  nystagmus. 
Well-marked  fatuity  was  a  striking  symptom  with  a  tend- 
ency to  alternate  silly  laughter  and  depression.  Hand- 
writing showed  slight  tremor ;  pronounced  tremulousness 
about  the  muscles  of  the  angle  of  the  mouth  and  slightly 
marked  speech  defect.  (Abstract,  Berkley,  Mental  Dis- 
eases, p.  172.) 

A     CASE     OF     GENERAL     PARESIS     IN     THE     SECOND     STAGE 
ATTACKED    WITH    CONVULSIONS    WHICH    PROVED    FATAL. 

H.  P.,  in  second  stage  of  general  paralysis,  was  mildly 
excited  and  subject  to  extravagant,  grandiose  delusions, 
yet  able  to  read,  write,  or  converse  in  a  connected  strain 
of  thought,  so  long  as  his  delusional  ideas  were  not 
entrenched  upon.  Suddenly  seized  with  epileptiform  con- 
vulsions, commencing  on  left  side  of  the  body,  but  usually 
spreading  to  the  opposite  side ;  such  seizures  occurring 
several  times  during  the  day  and  night,  and  lasting  for 
several  days  together.  After  their  cessation,  he  was  left 
in  a  condition  of  profound  imbecility,  from  which  he  never 
rallied  ;  persistent  and  copious  watery  alvine  evacuations 
accompanied  the  attacks.  (Abstract,  Lewis,  Mental  Dis- 
eases, 2d  ed.,  p.  297.) 

THE     FOLLOWING     "PROCLAMATION"    WAS     ISSUED     BY     A 

PARETIC,    WHICH     IS     AN     EXCELLENT     EXAMPLE    OF 

THE    EXALTATION    OF    SELF    IN    THIS    DISEASE. 

"To  all  the  people  and  inhabitants  of  the  United  States 
and  all  the  outlying  countries,  greeting  : 

"I,  John  Michler,  King  of  the  Tuskaroras,  and  of  all 
the  islands  of  the  sea,  and  of  the  mountains  and  valleys 
and  deserts ;  Emperor  of  the  Diamond  Caverns,  and  Lord 
High  General  of  the  armies  thereof ;  First  Archduke  of 
the  Beautiful  Isles  of  the  Emerald  sea.  Lord  High  Priest 
of  the  Grand  Lama,  etc.,  etc.,  etc.,  do  issue  this  my 
proclamation.  Stand  by  and  hear,  for  the  Lord  High 
Shepherd  speaks.  No  sheep  have  I  to  lead  me  around, 
no  man  have  I  to  till  me  the  ground,  but  the  sweet,  little 


SECOND    STAGE.  63 

cottage  is  all  my  store,  and  the  room  that  I  sleep  in  has 
ground  for  the  floor.  No  chair  have  I  to  sit  myself  down, 
no  meat  have  I  to  eat  myself  down,  but  the  three-legged 
stool  is  the  chief  of  my  store,  and  my  neat  little  cottage 
has  ground  for  the  floor.  No  children  have  I  to  play  me 
around,  no  dog  have  I  to  bark  me  around,  but  the  three- 
legged  stool  is  the  chief  of  my  store,  and  my  neat  little 
cottage  has  ground  for  the  floor. 

"Yea,  verily,  I  am  the  Mighty  King,  Lord  Archduke, 
Pope  and  Grand  Sanhedrim,  John  Michler.  None  can 
with  me  compare,  none  fit  to  comb  my  hair,  but  the  three- 
legged  stool  is  the  chief  of  my  store,  and  my  neat  little 
cottage  has  ground  for  the  floor.  John  Michler  is  my 
name.     Selah ! 

"I  am  the  Great,  All-Bending,  Rip-Roaring  Chief  of 
the  Aborigines  I  Hear  me  and  obey  !  My  breath  over- 
throws mountains  ;  my  mighty  arms  crush  the  everlasting 
forests  into  kindling-wood ;  I  am  the  owner  of  the  ebony 
plantations ;  I  am  the  owner  of  all  the  mahogany  groves 
and  of  all  the  satin-wood;  I  am  the  owner  of  all  the 
granite ;  I  am  the  owner  of  all  the  marble ;  I  am  the 
owner  of  all  the  owners  of  everything.  Hear  me  and 
obey  !  I,  John  Michler,  stand  forth  in  the  presence  of  the 
Sun  and  of  all  the  Lord  Suns  and  Lord  Planets  of  the 
Universe,  and  I  say.  Hear  me  and  obey  !  I,  John  Michler, 
on  this  eighteenth  day  of  August,  do  say.  Hear  me  and 
obey  !  for  with  me  none  can  equal,  no,  not  one,  for  the 
three-legged  stool  is  the  chief  of  my  store,  and  my  neat 
little  cottage  has  ground  for  the  floor.  Hear  me  and  obey  ! 
Hear  me  and  obey  !     John  Michler  is  my  name. 

"John  Michler,  First  Consul  and  Dictator  of^he  World, 
Emperor,  Pope,  King,  and  Lord  High  Admiral,  Grand 
Liconthropon  forever ! "  (Abstract,  Hammond  on  In- 
sanity, p.  603.) 


CHAPTER   VI. 

THE    SYMPTOMS    OF    GENERAL    PARESIS    {coflttnued). 

The  demarcation  between  the  second  and  third 
stages  is  not  clearly  defined  and  may  not  always  be 
determined  unless  looked  for  closely.  This  is  espe- 
cially true  of  cases  in  which  no  episodal  phenomena 
mark  the  transition.  Cerebral  seizures  are  not  un- 
common in  the  latter  part  of  the  second  stage  and 
when  one  of  these,  as  an  epileptiform  fit,  occurs,  the 
patient  may  be  thrown  abruptly  into  the  third  or  ter- 
minal stage. 

Third  Stage.     {Fourth  Period.)    Mental  Symptoms. 

The  progressive  failure  of  mental  integrity,  which 

we  have  seen  slowly  taking  place,  finally  reaches 
the  point  of  complete  dementia  or  amentia  in  this 
terminal  stage.  The  patient  in  whom  speech-power 
is  practically  abolished  has  now  reached  the  point  ol 
fatuity  in  almost  the  entire  quenching  of  all  of  the 
higher  aptitudes  of  mind.  This  impairment  is  seen 
in  all  the  content  of  consciousness— thinking,  feeling 
and  volition.  As  one  author  aptly  says :  "  The  patient 
actually  falls  into  the  condition  of  a  lower  order  of 
being,  more  resembling  a  vegetable  with  a  digestive 
tube^than  an  animal"  (Macpherson). 

Third  Stage.  {Fourth  Period.)  Physical  Symp- 
toms.— The  reduction  seen  in  the  mental  sphere  may 
also  be  seen  in  that  of  the  physical.  The  prosperous 
appearance  which  ample  weight  gives  to  the  patient 
in  the  second  stage  disappears  often  in  this  by  evi- 
dences of  great  loss  of  flesh.  The  exhaustion  and 
emaciationbecome  so  pronounced  in  some  cases  as 

64 


PUte  IV. 


THIRD  STAGE  OF  GENERAL  PARESIS. 


THIRD    STAGE.  65 

the  end  approaches  that  the  patient  is  reduced  almost 
to  a  skeleton. 

The  muscular  incoordination  and  paresis  advance  to 
the  extreme  degree.  The  muscular  tremor  is  shown 
by  the  utmost  trembling  and  shakiness.  The  gait  gets 
more  and  more  unsteady  until  the  patient  falls  with  any 
attempt  at  taking  a  step;  standing  alone  unguarded 
soon  becomes  impossible  and  seated  his  body  falls  in 
upon  itself,  so  there  is  danger  of  pitching  forward  on 
the  floor.  The  impracticability  of  getting  him  out 
of  bed  soon  leads  to  his  complete  decubitus.  Con- 
traction of  his  legs,  in  a  flexed  position,  gradually 
increases,  producing  in  some  cases  much  deformity. 

A  marked  change  takes  place  in  the  speech  of  the  pa- 
tient, which  is  reduced  to  the  formation  of  very  simple 
phrases;  many  of  the  troubles  already  noticed  still  ex- 
ist but  in  a  more  pronounced  form.  The  voice  may  be- 
come rough  and  hoarse,  or  it  may  become  weak  and 
monotonous,  always  the  result  of  relaxing  of  the  vocal 
cords.  Ideas  become  more  fragmentary,  word-deaf- 
ness and  word-blindness  may  follow.  Speech  becomes 
more  tremulous  until  the  patient  speaks  very  little,  or 
toward  the  end  not  at  all.  In  some  cases  there  is  an 
inarticulate  shouting,  especially  at  night,  while  in 
others  there  is  but  an  occasional  meaningless  moan. 

The  deep  tendon  reflexes  are  usually  permanently 
abolished  and  the  pupils  no  longer,  as  a  rule,  respond 
to  light  and  accommodation.  The  face  has  now  lost 
its  entire  expression,  and  the  paucity  of  mind  is  re- 
flected in  the  vacant  look.  Trophic  changes  soon 
appear  in  various  aggravated  forms.  The  most  com- 
mon and  invariable  are  bed-sores  over  the  sacral 
region,  where  not  only  pressure  but  irritating  dis- 
charges tend  to  increase  the  complication.  It  is 
occasionally  stated  that  bed-sores  have  their  origin 
in  poor  nursing  and  that  the  occurrence  may  be.  ob- 
6 


66  SYMPTOMS    OF    GENERAL    PARESIS. 

viated  by  care  and  skill.  There  can  be  no  doubt  that 
much  can  be  done  in  this  way,  as  a  preventive  meas- 
ure, but  there  are  some  cases  where  no  precaution  can 
avail,  when  even  the  contact  of  bed-clothing  is  suffi- 
cient to  produce  sores  and  every  pendent  point,  knee, 
elbow,  heel  and  back  may  be  the  seat  of  invasion. 
In  some  cases  the  nervous  enervation  is  so  great  that 
erythemas,  abscesses,  perforating  ulcers  of  the  foot,  the 
shedding  of  the  nails  and  teeth  and  extensive  sloughs 
of  different  parts  of  the  body  may  be  encountered. 

In  this  helpless  state  the  wretched  sufferer  lies  day 
after  day,  with  nearly  every  semblance  to  a  rational 
being  extinct,  until  death  puts  an  end  to  the  scene. 

ILLUSTRATIVE    CASE    IN    THE    THIRD    STAGE. 

J.  E.  J.,  xt.  44,  now  presents  the  conditions  of  the  final 
stage,  the  previous  stages  having  been  typical.  He  can- 
not walk  or  stand,  but  lies  in  bed  in  the  position  in  which 
he  may  be  placed,  barely  able  to  turn  his  body  unassisted. 
He  is  now  unable  to  articulate  more  than  a  word  or  two  at 
a  time.  His  flesh  is  fast  wasting,  swallows  with  difficulty, 
and  is  fed  chiefly  with  liquid  food.  His  dejections  pass 
unconsciously  in  bed.  But  the  expression  of  good  feeling 
still  lingers  on  his  face  and  he  never  complains.  When 
addressed  he  sometimes  tries  to  reply  and  even  to  smile  a 
recognition,  but  does  not  succeed  and  the  semi-flaccid 
muscles  of  the  mouth  and  face  fail  in  their  effort  of  move- 
ment. Bed-sores  are  hard  to  prevent.  He  will  become 
even  thinner  than  at  present  unless  the  drama  ends  by  a 
paralysis  of  the  muscles  of  deglutition.  (Abstract,  Stearns, 
Mental  Diseases,  p.  505.) 

ILLUSTRATIVE    CASE    IN    THE    THIRD    STAGE. 

F.  W.,  aet.  40,  has  had  general  paresis  for  two  years 
and  has  passed  through  the  first  and  second  stages.  He 
is  so  paralyzed  that  he  cannot  walk,  stand  steadily,  or 
write  ;  his  mental  state  is  that  of  a  happy  lethargy.  When 
asked  if  he  has  much  money,  his  facial  muscles  begin  to 


THIRD    STAGE.  67 

act  in  an  incoordinated  way,  his  eyelids  half  shutting,  his 
mouth  being  drawn  in, -the  lips  moving  spasmodically  like 
a  patient  going  into  an  epileptic  fit,  the  whole  effect  being 
that  of  a  contorted  imitation  of  a  smile,  accompanied  by  a 
slow,  prolonged  and  jerky  "  y-a-a-a,"  which  is  all  that  he 
can  articulate  for  "  yes."  But  he  looks  perfectly  happy, 
and  asks  for,  and  complains  of  nothing.  He  is  unable  to 
retain  urine  and  feces  by  night  or  day.  All  his  food  has  to 
be  liquid  or  minced,  for  he  would  bolt  it  in  solid  masses  and 
choke ;  he  is  greedy  for  food  when  it  is  put  into  his 
mouth,  though  unable  to  feed  himself.  He  had  a  con- 
gestive attack  about  the  end  of  the  first  stage  of  the  dis- 
ease, accompanied  by  unconsciousness  ;  a  temperature  of 
103°,  and  general  convulsions  which  began  and  ended  on 
the  right  side,  but  affected  the  whole  body  in  the  middle 
of  the  attack  ;  they  lasted  for  about  four  hours  and  were 
succeeded  by  stupor,  which  lasted  for  forty-eight  hours. 
He  had  retention  of  urine  as  he  slowlv  recovered  con- 
sciousness ;  after  that,  his  speech  and  walking  were  more 
paretic,  and  his  mental  power  more  enfeebled.  The 
second  attack  was  of  the  same  character,  though  less 
severe  and  occurred  in  the  second  stage.  His  common 
sensibility  is  so  impaired  that  you  can  stick  pins  in  him 
wdthout  his  feeling  it  much.  The  reflex  action  of  his  cord 
is  over-acute  and  extends  upwards  from  the  section  of  the 
cord  irritated,  for  if  you  tickle  the  foot,  they  are  both 
drawn  up  with  a  jerk,  and  the  two  hands  and  chest 
muscles  are  contracted  likewise.  The  impression  travels 
upwards  more  readily  than  downwards.  (Abstract,  Clous- 
ton,  Mental  Diseases,  4th  ed.,  p.  385.) 

GENERAL    PARESIS    FOLLOAVIXG   A    GREAT    MENTAL    SHOCK. 

SAPID  IMPROVEMENT.     REMISSION  AND  RELAPSE.    DEATH 

IN    TWO  YEARS    FROM    COMMENCEMENT  OF  ATTACK. 

A  solicitor,  at.  58,  highly  esteemed  and  in  large  prac- 
tice, met  with  severe  family  affliction  and  reverses.  After- 
wards was  altered  in  manner,  committed  many  strange  acts, 
indifferent  to  his  troubles,  disposed  to  quarrel,  peevish. 
Undertook  several  large  schemes  at  variance  with  his  cau- 


68  SYMPTOMS    OF    GENERAL    PARESIS. 

tious  temperament.  He  would  tell  his  confidences  to  people 
almost  strangers.  Conduct  at  home  strange  and  excited  ; 
would  not  go  to  bed,  said  he  was  attacked  by  Fenians  (an 
attempt  recently  made  on  the  Queen  greatly  alarmed  him). 
Accused  a  Mr.  F.  of  being  his  enemy.  Mr.  F.  was  a  Fe- 
nian. He  had  all  his  windows  and  doors  barricaded  ;  had 
a  forced  cordial  manner,  very  garrulous.  On  admission, 
general  appearance  good,  was  said  to  have  been  four 
weeks  ill,  in  elated  spirits,  talked  much  of  his  schemes, 
would  cut  a  canal  from  the  west  of  England  to  the  mouth 
of  the  Severn,  so  that  ships  could  go  to  Gloucester  and 
Cheltenham  ;  would  build  towns  in  the  Cotswold  Hills  and 
a  cathedral.  He  would  try  to  improve  agriculture  and 
thus  make  a  large  fortune.  Said  Mr.  F.  was  a  great  de- 
bauchee, his  conversation  interlarded  with  much  prurient 
matter ;  easily  diverted  from  one  topic  to  another ;  open 
to  slight  flatter}^  bragged  of  his  own  cunning  ;  was  relieved 
to  be  admitted  and  in  security  against  his  foes  ;  fancies  he 
is  in  a  cave  in  Leckhampton  Hills  (was  admitted  after 
dark) ;  decorated  himself  with  a  blue  scarf  but  when  talked 
to  quietly,  was  ashamed  and  removed  it.  The  day  after 
admission,  found  out  where  he  was  and  pretended  he  was 
much  pleased,  praised  all  the  appointments,  said  he  would 
buy  the  institution,  lost  his  fear  of  Fenians.  Occupied 
himself  in  drawing  the  scheme  for  the  cathedral.  Said 
he  should  spend  several  millions,  that  the  Queen  would 
grant  him  an  annuity  of  £10,000  and  each  of  his  daughters 
£5,000.  His  fear  of  enemies  returned  every  evening.  A 
fortnight  after  admission,  sixth  week  after  disease :  He  is 
always  elated  in  spirits,  jokes  with  the  most  insane  patients 
and  considers  them  perfectly  rational.  One  month  after 
admission  :  Same  symptoms  continue,  grand  ideas,  etc.,  lib- 
idinous conversation,  fears  increase  towards  evening.  Five 
weeks  after,  visited  by  wife  and  friends  ;  at  first  refused  to 
see  them,  then  received  them  cordially  ;  thought  his  wife  had 
sided  with  Mr.  F.,  but  fears  the  latter  less  than  formerly; 
he  has  a  sense  of  weight  in  his  limbs,  eats  largely.  Eighth 
week  :  Spent  a  day  at  home  ;  has  lost  his  fears,  converses 
rationally,  expression  much  improved,  says  he  feels  well. 


THIRD    STAGE.  69 

Ninth  week  :  Left  for  six  weeks  on  probation  ;  relatives 
consider  him  well ;  has  been  quiet  and  rational ;  has  slight 
feebleness  of  intellect,  makes  puerile  remarks,  a  certain 
lameness  in  his  conversation,  heavy  expression  of  face, 
is  too  much  elated  over  his  health,  bulimia  continues,  feels 
no  weight  in  his  limbs.  Fifteenth  week  :  received  me  cor- 
dially, jokes  about  his  former  delusions,  all  he  requires,  he 
said, is  his  former  strength.  He  was  discharged  "relieved." 
A  note  received  shortly  after  from  him,  thanked  me  for 
care  and  attention,  said  his  legs  still  felt  weak.  On  his 
discharge,  he  remained  at  home,  unable  to  return  to  busi- 
ness, his  mind  gradually  declining,  talked  in  a  childish 
way,  fond  of  prurient  anecdotes,  gradually  neglected  his 
personal  appearance  ;  was  found  one  day  sitting  down  on 
the  curb-stone.  Having  been  discharged  in  March  he  was 
readmitted  in  the  following  August  and  died  in  December, 
two  years  from  the  commencement  of  the  attack.  (Abstract, 
Sankey,  Mental  Diseases,  p.  315.) 

PERIPHERAL    NEURITIS    IN    THE    COURSE    OF    GENERAL 
PARESIS. 

The  patient  was  an  imbecile  whose  mother  was  insane. 
When  aged  22,  he  began  to  have  characteristic  symptoms 
of  general  paresis.  He  had  delusions  of  grandeur,  stutter- 
ing speech,  twitching  of  tongue  and  facial  muscles  ;  and 
pupils  sluggish  to  light.  After  he  had  become  confined 
to  bed,  there  was  paralysis  of  the  peronei  muscles,  which 
disappeared  after  several  months  and  was  succeeded  by 
spastic  rigidity.  (Abstract,  Pick,  Berliner  klinische  Wo- 
chenschrift,  No.  47,  90.) 

GENERAL    PARESIS    DUE    TO    BUSINESS    WORRY,    INTER- 
RUPTED   BY    A    REMISSION    AND    MARKED    IN    THE 
LAST    STAGE    WITH    CONVULSIONS. 

Henry  W.,  married,  set.  37,  silver  chaser,  no  insane 
relatives,  the  first  attack  due  to  business  anxieties ;  first 
symptoms  appeared  two  months  before  admission,  when 
he  bought  a  plot  of  land  without  being  able  to  pay  for  it. 
He  talked  about  travelling  and  taking  a  hundred  friends 


7©  SYMPTOMS    OF    GENERAL    PARESIS. 

with  him  ;  was  going  to  build  a  large  house ;  become  an 
M.P.  and  was  full  of  extravagance  and  joyousness.  On 
admission,  he  was  sleeping,  eating,  digesting  well,  pupils 
contracted,  with  tremor  and  hesitation  of  speech,  change  in 
handwriting  and  restlessness.  This  attack  passed  away 
and  in  two  months  he  was  sent  to  the  convalescent  home, 
and  was  finally  discharged,  his  friends  being  warned  that  it 
was  only  a  remission.  In  six  months  he  was  brought  back, 
having  slept  well  till  ten  days  before  admission.  He  then 
became  extravagant  and  did  not  know  the  value  of  money. 
He  collected  rubbish,  thinking  it  gold,  talked  with  much 
hesitation  of  speech,  about  millions  and  the  hippopotami 
he  was  going  to  stock  his  farm  with.  Expression  dull ; 
tremor  of  lips  and  tongue  ;  pupils  small  and  equal ;  skin 
greasy ;  speech  clipped  and  hesitating ;  memory  bad ; 
restless  and  mischievous,  tearing  books  and  clothes ;  no 
change  in  his  optic  discs.  He  improved  in  bodily  health, 
fat  and  healthy  looking.  In  a  year's  time  he  had  a  fit,  the 
temperature  not  being  raised  and  only  slight  convulsions, 
associated  with  unconsciousness.  From  time  to  time  he 
had  fits,  alwa3^s  of  the  following  nature  :  Without  warning, 
fell  forward  on  the  floor,  limbs  twitching  slightly,  uncon- 
scious for  from  ten  minutes  to  an  hour,  passing  his  urine 
and  feces  under  him.  Recovery  was  like  one  waking  from 
sleep  ;  each  fit  leaving  him  slightly  weaker  mentally.  In 
six  months  more,  vision  was  noticed  to  be  weak,  pupils 
contracted  but  not  circular,  right  optic  disc  very  white, 
edges  very  sharply  defined ;  left  optic  disc  pale,  sharply 
defined;  knee-jerk  well  marked.  He  said  he  was  "very 
well."  The  fits  recurred  ;  but  during  the  last  month  of  his 
life  he  at  times  could  talk  accurately  about  events  that 
happened  two  years  before,  in  the  hospital.  In  two  years 
after  admission  he  became  unable  to  swallow,  lost  flesh 
rapidly  and  died.     (Abstract,  Savage  on  Insanity,  p.  323.) 

GENERAL    PARESIS,    DURATION    ABOUT    TWO    YEARS. 
DEATH    IN    THE    THIRD    STAGE. 

A.   S.,   a  female,  married,   aet.   32,   admitted  in  June  ; 
married  twelve  years ;  previously  a  domestic  servant,  of 


THIRD    STAGE.  7 1 

excellent  character ;  lived  with  her  grandfather,  a  man 
very  much  respected ;  of  short  stature,  of  considerable 
personal  attractions  ;  had  several  children  ;  her  health  fail- 
ing, she  returned  to  her  grandfather,  having  been  infected 
with  syphilis  by  her  husband  ;  one  or  two  of  her  children 
died.  On  the  death  of  one,  the  patient's  attack  commenced, 
she  being  found  insensible  on  the  twenty-fourth  of  Decem- 
ber. In  June  following  she  was  arrested  for  pulling  up 
trees  in  a  nursery,  threw  her  arms  around  two  men  on  the 
street  and  kissed  them  ;  her  house  was  the  scene  of  drinking 
and  other  immoralities  ;  her  children  neglected  and  dirty  ; 
her  sister  said  the  first  appearance  of  the  disease  was  shown 
by  her  ordering  a  large  quantity  of  furniture.  On  admis- 
sion very  dirty,  temperate,  well-nourished,  dark  hair  and 
irides,  slight  paresis  about  lips  and  face.  Expression  some- 
what imbecile  ;  is  reported  to  have  been  six  months  ill  on 
admission.  Second  day  after  admission,  is  excited  and 
talkative,  says  God  is  very  gracious  ;  has  a  very  nice  hus- 
band, two  children,  is  going  to  Margate,  etc.  ;  hesitates 
and  drawls  in  her  speech.  Tongue  protruded  by  an  effort, 
not  tremulous,  coated.  Says  she  has  £17,000,  that  her  hus- 
band has  40  and  then  70  millions.  She  is  feeble,  at  times, 
wet  and  dirty,  disposed  to  undress,  requiring  the  dress  to 
be  fastened  mechanically.  Sixth  month  after  admission, 
twelfth  of  disease,  complains  of  headache  ;  eyelids  swollen, 
and  crying,  is  destructive  and  violent,  articulation  indis- 
tinct, hand  tremulous,  says  she  has  "such  beautiful  senti- 
ments." Tenth  month,  has  not  spoken  for  several  weeks 
till  to-day,  imbecile  and  childish,  voice  tremulous  and 
stammering,  twitching  of  both  lips,  pupils  nearly  equal, 
peculiar  gait,  no  grand  ideas,  is  stouter,  tongue  clean, 
protruded  well,  is  wet  and  dirt\'.  A  seton,  inserted  in  the 
neck,  caused  no  pain.  Eleventh  month,  able  to  stand  but 
very  tottering,  expression  slightly  improved,  knew  her 
mother,  and  glad  to  see  her,  speaks  seldom,  lies  quietly 
in  bed,  conversed  with  her  mother,  right  pupil  large. 
Seton  discharges  well.  Twelfth  month,  slight  improve- 
ment, speaks  more  cheerfully,  she  can  stand  more  firmly, 
walked  without  assistance  to  bath,  takes  food  well,  is  well 


72  SYMPTOMS    OF    GENERAL    PARESIS. 

nourished.  Twelve  and  a  half  months,  answers  questions 
more  alertly,  says  she  feels  well,  can  w^alk  with  the  assist- 
ance of  one  person,  right  pupil  dilated.  Thirteenth  month, 
when  in  bed  began  to  lie  with  knees  drawn  up,  cannot 
stand  alone.  Fourteenth  month,  knees  constantly  drawn 
up,  is  weaker  and  more  restless.  Fifteenth  month,  mind 
childish  but  not  wandering,  not  excited,  knows  where  she 
is,  articulation  hesitating,  syllables  slurred,  tongue  pro- 
truded well,  wet  and  dirty,  knees  drawn  up,  says  she  can- 
not put  the  right  knee  down.  Fifteen  and  a  half  months, 
is  getting  thinner,  both  knees  contracted,  visited  by  her 
mother,  asked  for  her  children,  soon  after  forgot  that  her 
mother  had  been  to  see  her,  takes  food  well  and  swallows 
without  difficulty,  says,  "  I  like  food  very  much."  Eight- 
eenth month,  continued  confined  to  bed,  gradually  getting 
weaker,  appetite  still  good,  called  for  food  at  the  proper 
hour,  bowels  acted  regularly,  continued  to  emaciate  though 
she  took  food  ravenously.  Both  legs  contracted,  said  she 
was  going  to  die,  voice  clear  and  stronger,  but  tremulous 
and  bleating,  sank  and  died  without  convulsion  or  other 
marked  change.     (Abstract,  Sankey,  of.  cit.,  p.  316.) 

A    CASE    OF    GENERAL    PARESIS    PROBABLY    SYPHILITIC. 

MENTAL    INTEGRITY    YERY    GOOD.        DIED    IN 

CONVULSIONS    IN    THE    THIRD    STAGE. 

D.  N.,  aet.  59.  Probably  a  syphilitic;  at  any  rate,  a 
gonorrheal  history.  Excited  and  exalted  ;  declared  this 
to  be  heaven,  and  a  few  days  later  said  he  had  been  around 
the  world  in  the  last  two  days.  Pupils  small,  immobile  ; 
tongue  protrusion  jerky;  speech  thick  and  interrupted. 
He  said  he  had  a  letter  about  his  wife  and  that  she  was 
dead — a  delusion.  Pains  in  right  side  followed  by  hemi- 
plegia. Accessions  and  recessions  of  strength  from  day 
to  day.  For  a  general  paralytic,  he  was  very  accurate  in 
observing  and  reporting  his  symptoms.  Hallucinations  of 
siglit  and  taste.  Bed-sores  on  right  buttock,  blisters  (trophic 
neurosis)  running  down  right  arm  and  wrist,  later  on  left 
arm  ;  then  coma,  convulsions  and  death.  (Abstract, 
Campbell  Clark,  Mental  Diseases,  p.  222.) 


CHAPTER   VII. 

VARIETIES    OF    GENERAL    PARESIS. 

In  attempting  to  classify  cases  of  general  paresis, 
considerable  difficulty  is  experienced  at  once.  There 
seems  to  be  no  very  clearly  cut  divisions  at  present, 
based  either  on  therapeutics,  pathology  or  clinical 
history  into  which  these  cases  can  be  separated.  The 
varieties  are  divided  by  Spitzka  simply  into  two  types; 
in  the  first  of  which  the  affection  is  the  ordinary  type; 
the  second  is  that  in  which  the  mental  symptoms 
appear  after  serious  evidence  of  a  spinal  or  axial  affec- 
tion of  the  nervous  system,  and  hence  this  author 
terms  this  form  the  "ascending  affection." 

Savage  divides  the  cases  into  acute  and  chronic 
and  then  into  those  in  which  the  symptoms  are  pri- 
marily maniacal  with  exaltation  of  ideas;  next  the 
melancholic  and  hypochondriacal  cases;  and  lastly 
those  in  which  dementia  is  more  or  less  pronounced 
from  the  onset.  He  states  that  it  will  be  seen  in 
tracing  the  history  of  cases  that  nearly  all  end  in 
dementia  sooner  or  later.  In  another  division  he  con- 
siders whether  the  brain  or  cord  symptoms  are  most 
marked,  or  come  on  earliest.  In  considering  the 
latter,  he  divides  the  cases  into  those  in  which  the 
posterior  columns  of  the  cord  are  most  affected,  and 
those  in  which  the  lateral  columns  are  chiefly  involved. 

Folsom,  in  Pepper's  System  of  Medicine,  states  that 
well-marked  general  paresis  can  be  divided  into  four 
distinct  types,  as  follows: 

(i)  The  demented  and  paralytic;  (2)  the  hypochon- 
driacal; (3)  with  melancholia;  (4)  with  exaltation  and 

73 


74  VARIETIES    OF    GENERAL    PARESIS. 

mania.  There  are  mixed  cases  in  which  some  or 
all  of  these  forms  occur.  Folsom  also  believes 
that  the  period  of  invasion  or  prodromal  period, 
be  it  short  or  long,  has,  as  a  rule  (not  always), 
gone  by  when  the  disease  has  arrived  at  a  point 
in  its  progress  to  be  definitely  placed  in  any  of  these 
four  t3'pes. 

B.  Lewis  ^  goes  into  the  varieties  of  general  paral3''sis 
in  greater  detail  and  produces  a  plan  of  clinical  group- 
ings in  which  he  feels  that  all  forms  of  general  paral- 
ysis ma}'  be  included;  this  scheme  is  based  upon  the 
predominance  of  the  cerebral,  bulbar  or  spinal  symp- 
toms, their  earl}-  on  late  onset  and  the  clinical  course 
pursued. 

Group  I. — Paralytic  m3'driasis;  a  partial  reflex 
iridoplegia  (light).  Increased  myotatic  irritability. 
Excessive  facial  tremor  and  speech  troubles.  Great 
optimism  with  profound  dementia. 

Group  2. — Mydriasis  with  associated  iridoplegia 
rapidl}'  passing  into  the  c3'cloplegic  form — an  early 
S3'mptom.  Frequent  m3'otatic  excess,  but  no  con- 
tractures. Late  speech  troubles.  Acute  excitement 
with  frequent  convulsions.  Ver3'  rapidl}'  fatal  course 
(preponderance  of  S3'philitic  histor3"). 

Group  J. — Spastic  m3^osis;  a  complete  reflex  iri- 
doplegia. Absent  or  greatl3'  impaired  knee-jerk. 
Failure  of  equilibration;  locomotor  atax3%  defective 
sensibilit3'.  Ver3"  defective  articulation.  Much  opti- 
mism and  excitement. 

Group  4. — Late  e3^e  symptoms :  paral3'tic  m3'dria- 
sis,  a  partial  reflex  iridoplegia  (for  light  only).  Ataxic 
paraplegia  confined  to  lower  extremities  (arms  do  not 
participate).  Great  facial  atax3'  with  extreme  troubles 
of  speech.  Epileptiform  seizures  ushering  in  pro- 
nounced mental  enfeeblement. 

'  Mental  Diseases,  2d  ed.,  p.  326. 


VARIETIES.  75 

Groiip  5. — No  oculo-motor  symptoms  beyond  oc- 
casional inequality.  No  contractures,  but  notable 
myotatic  excess.  No  disturbance  of  equilibration, 
locomotion,  or  sensation.  Speech  troubles  not  pro- 
nounced. Epileptiform  seizures  very  rare,  but  from 
the  first  progressive  deepening -dementia. 

The  French  writers,  according  to  Sankey,^  divide 
the  disease  into  four  varieties  as  follows : 

1.  A  congestive  variety. 

2.  A  paralytic  variet}'. 

3.  A  melancholic  variet}^ 

4.  An  expansive  variety. 

M.  Baillarger  insisted  upon  a  h3'pochondriacal,  a 
melancholic,  a  monomaniacal,  and  a  simple  form.  It 
is  therefore  abundantly  evident  that  the  cases  of  gen- 
eral paresis  show  certain  deviations  in  the  course  of 
the  disease,  but,  nevertheless,  Sankey  believes  that 
there  will  be  found  running  through  the  whole  of 
each  case  more  or  less  pronounced  general  symptoms. 

Every  writer  upon  the  disease  admits  that  such 
variation,  also,  in  the  advent  of  the  various  phe- 
nomena, is  not  uncommon.  As  regards  the  order  of 
occurrence  of  the  mental  and  motor  symptoms,  for 
instance,  Sankey^  states  that  there  are  described  three 
modes  of  invasion  as  possible. 

Firstly,  the  case  may  commence  by  some  disorder 
of  the  mental  faculties  —  usually  by  delirium,  or 
maniacal  excitement — but  in  some  cases  with  depres- 
sion or  melancholy,  and  on  the  subsidence  of  these 
symptoms  the  peculiar  indications  of  general  paresis, 
particularly  those  connected  with  the  motor  functions, 
manifest  themselves.  This  is  admitted  by  most 
authors  to  be  the  most  frequent  order  of  invasion. 
Both   Parchappe   and  Calmeil   agreed  also   that  the 

^Mental  Diseases,  p.  277. 
^  Op.  ctt.,  p.  277. 


76  VARIETIES    OF    GENERAL    PARESIS. 

special  paretic  symptoms  may  follow  the  mental  at 
any  length  of  time,  as  after  many  years,  though  this 
is  exceptional  and  not  the  usual  course. 

Secondly,  other  cases  occur,  in  which  the  mental 
symptoms,  as  mania,  melancholia  and  especially  a 
state  of  dementia,  are  manifested  simultaneously  with 
the  lesion  of  motility. 

Thirdly,  MINI.  Baillarger  and  Lunier  asserted  that, 
as  a  rule,  the  lesion  of  motility  precedes  the  mental 
phenomena. 

Voisin,  the  well-known  authority,  has  given  five 
forms  of  general  paresis : 

1.  Acute  general  paresis  in  which  the  course  is 
rapid,  the  stages  are  confounded,  and  death  occurs 
early  as  a  rule.  It  may  suddenly  attack  an  apparently 
healthy  person  without  an}'  warning. 

2.  The  common  form  of  general  paresis  in  which 
the  mental  state  is  generally  expansive  and  ambitious. 
Often  accompanied  by  epileptiform  and  apoplectiform 
attacks. 

3.  The  form  in  which  symptomsof  dementia  predom- 
inate (paralytic  dementia).  It  is  the  chronic  form  par 
excellence,and  is  accompanied  byfewsomatic  troubles. 

4.  The  senile  form  connected  with  atheroma  of  the 
arteries.  In  its  course  it  is  next  in  rapidity  to  form  i. 
It  is  very  rare. 

5.  The  spinal  form  in  which  the  medullary  troubles 
dominate  the  scene,  and  the  intellectual  are  of  sec- 
ondary importance.  It  is  very  irregular  in  its  mani- 
festations.    (Shaw,  Epitome  Mental  Diseases,  p.  77.) 

Another  division  of  general  paresis  is  into  four 
forms,  three  of  which  depend  on  the  character  of  the 
mental  symptoms,  and  the  fourth  on  their  absence  or 
significance:  (i)  the  expansive  form;  (2)  the  depres- 
sive or  melancholy  form;  (3)  the  demented  form; 
(4)  the  somatic  form  (Shaw). 


VARIETIES.  77 

Mickle,  in  his  classic  work,  has  laid  down  five 
groups  into  which  general  paresis  can  be  divided. 
The  first  group  consists  of  cases  of  a  common  kind, 
which  exhibit  exalted  delusions,  maniacal  excitement 
and  hallucinations.  The  duration  of  this  condition  is 
short;  cerebral  hyperemia  and  softening  are  observed 
with  adhesion  and  decortication.  In  the  second  group 
there  is  found  a  protracted  stage  of  dementia,  the 
quiet  self-satisfaction  of  the  early  stage  being  followed 
by  peevishness  or  apprehension,  till  the  personal 
habits  become  foul  and  brutish.  The  duration  of  this 
condition  is  length}-,  and  the  brain  seen  to  be  atro- 
phied with  considerable  increase  of  intracranial 
serum.  The  gyri  of  the  upper  surface  and  frontal 
region  are  wasted,  adhesion  and  decortication  are 
moderate,  and  the  white  substance  is  pale.  In  the 
third  group  dementia  is  early  and  predominant,  and 
melancholic  delusions  are  common,  the  latter  course 
of  the  disease  being  one  of  extreme  dementia. 
Hemiplegia  is  conspicuous  and  common,  epileptiform 
attacks  being  ver}^  frequent.  The  duration  of  this 
condition  is  brief  and  on  autopsy  the  left  hemisphere 
is  found  more  diseased  than  the  rio^ht  and  more  or 
less  atrophied.  In  the  fourth  group  the  morbid  le- 
sions are  much  more  conspicuous  in  the  right  than 
in  the  left  hemisphere.  The  outbreak  begins  with 
active  dehrium  and  maniacal  agitation,  the  symptoms 
of  dementia  and  melancholia  noticeable  in  the  third 
group  being  wanting.  The  duration  is  somewhat 
lengthy.  The  fifth  group  is  not  well  defined.  There 
is  much  local  induration  of  the  cortex  and  the  inter- 
stitial changes  tend  to  sclerosis;  the  mental  symp- 
toms are  various;  epileptiform  fits,  hemiplegia,  and 
spasms  are  frequent  and  the  duration  somewhat  long. 
(Blandford  on  Insanity,  p.  311.) 

Mickle  also  recognizes  eight  mental  varieties  in  the 


78  VARIETIES    OF    GENERAL    PARESIS. 

first  stage  of  general  paralysis.  These  are:  (i)  Symp- 
toms of  dementia  predominant,  in  which  are  found 
every  degree  of  mental  failure  and  deficiency.  (2) 
Expansive  delirium  is  predominant.  Here  grandiose 
ideas  and  a  feeling  of  elation  or  quiet  self-satisfaction 
are  actively  shown,  (3)  Mental  excitement  is  pre- 
dominant, with  probably,  though  not  necessarily, 
exaltation  and  grandiose  ideas.  There  may  be  excite- 
ment, mental  and  motor,  or  merely  silent  restiveness, 
or  what  is  described  as  the  galloping  form  of  general 
paralysis — raving,  violent,  sleepless,  with  t3'phoid-like 
symptoms.  (4)  H3^pochondriac  S3'mptoms  are  prom- 
inent. In  such  cases  the  essential  mental  state  may 
be  h3pochondria,  with  delusions  as  to  the  viscera, 
and  especiall3'  regarding  the  liver  and  bowels.  Ac- 
cording to  Mickle,  this  form  is  next  in  frequence  to 
the  expansive:  according  to  Clark's  experience  the 
first  class,  the  early  demented,  are  more  prevalent 
than  the  h3'pochondriacal.  (5)  Melancholic  symp- 
toms prominent.  (6)  Persecutor3'  delusions  prom- 
inent. (7)  Stuporose  form.  (8)  Circular  form. 
(Abstract,  Campbell  Clark,  Mental  Diseases,  p.  207.) 
According  to  a  few  writers  there  is  no  division  as 
satisfactor3'  as  that  of  "  Me3^nert's  Eight,"  which  is 
as  follows: 

1.  Simple  progressive  dementia  with  the  usual 
motor  impairment  which  accompanies  it,  but  except- 
ing h3^pochondrical  depression,  not  necessarily  ex- 
hibiting other  mental  S3'mptoms  than  dementia. 

2.  With  the  expansive  delusions  and  the  distinctive 
motor  disturbances  which  appear  simultaneously  and 
are  progressive,  constituting  the  "  classic  "  form  of 
general  paral3'sis.  The  mental  state  is  usuall3'  of  self- 
satisfaction  and  exultation,but  there  ma3'be  depression. 

3.  Of  the  same  t3'pe  as  the  last,  but  failing  its 
steadil3^  progressive  character  through  arrest  of  the 


VARIETIES.  79 

active  process.  The  remissions,  which  seldom  last 
so  long  as  a  year,  raise  hopes  of  recovery,  but  still 
manifest  unmistakable  impairment  of  the  reasoning 
faculties.  The  psychic  disturbances  are  much  greater 
than  can  be  accounted  for  by  the  atrophy  of  the  brain 
alone. 

4.  Cases  in  which  the  characteristic  exaltation  and 
grand  delusions  reach  such  an  astounding  height  that 
manifest  motor  symptoms  are  looked  for  with  con- 
fidence from  day  to  da}'  and  yet  may  not  appear  even 
for  a  year,  any  slight  incoordination  naturally  being 
obscured  by  the  general  muscular  disturbance. 
Meanwhile  there  may  be  such  an  improvement  that 
the  patient  leaves  the  hospital  for  awhile,  once,  rarely 
twice,  on  the  responsibility  of  his  famil}',  but  to  return 
with  marked  motor,  as  well  as  mental,  signs. 

5.  A  very  rare  form, with  alternate  symptoms  of  exal- 
tation and  depression  of  the  type  of  circular  insanity. 

6.  With  early  furious  delirium,  painful  hallucina- 
tions, confusion  and  incoherence  somewhat  resemb- 
ling acute  delirium. 

7.  Progressive  general  paralysis,  in  which  the 
characteristic  indications  appear  secondary  to  other 
forms  of  insanity;  for  instance,  after  paranoia  or 
melancholia,  first  described  by  Hoestermann. 

8.  The  combined  form  with  sclerosis  in  the  whole 
cerebro-spinal  tract,  the  symptoms  of  tabes  or  spastic 
paralysis  predominating,  according  as  the  posterior  or 
lateral  columns  of  the  spinal  cord  are  chiefly  involved. 
The  ascending  type,  in  which  the  cord  is  first  affected, 
is  rare.  Optic  neuritis  ending  in  atrophy  and  paraly- 
sis, especially  of  the  ocular  muscles,  may  precede 
marked  mental  symptoms.  (Folsom  per  Hughes, 
Practice  of  Medicine,  p.  472.) 

It  is  be3'ond  the  scope  of  this  work,  addressed  as  it  is 
to  the  medical  student  and  general  practitioner,  to  do 


8o  VARIETIES    OF    GENERAL    PARESIS. 

more  with  these  elaborate  classifications  than  to 
enumerate  them.  But  there  are  a  few  special  forms 
included  in  these  classifications  which  are  usually 
described  by  writers  that  may  appropriately  find  men- 
tion at  this  point. 

The  Galloping  Form. — As  the  name  suggests,  the 
galloping  form  acts  in  such  a  rapid  and  violent  man- 
ner that  within  a  few  months,  or  it  may  be  but  weeks, 
all  resistance  to  the  disease  is  overcome,  and  death 
follows  after  this  brief  time.  It  usually  assumes  a 
grave  aspect  from  the  first,  and  in  some  cases  mani- 
acal outbreaks  occur,  from  the  earliest  stage  of  the 
disease.  Many  times  early  exhaustion  supervenes, 
then  partial  collapse  and  lowered  temperature  are 
speedily  followed  by  death.  These  cases  are  similar 
to  those  of  acute  delirium,  and  with  these  are  often 
confused. 

Berkley  speaks  of  one  case  in  which  slight  irrita- 
bility and  alteration  of  disposition  was  followed  within 
two  weeks  by  excitement,  in  the  highest  degree,  with 
delirium  and  fever,  the  malady  running  its  course  in 
five  weeks.  The  same  author  records  another  case, 
who  recovered  from  this  attack  of  seeming  acute 
delirium  and  was  still  living  after  four  years,  but 
much  demented  and  showed  the  characteristic  pupils 
and  increase  of  knee-jerk. 

Zacher  reports  two  cases  of  acutely  progressive 
paresis,  the  first,  after  a  melancholic  prodromal  state, 
ran  its  course  in  less  than  four  weeks;  the  second, 
lasted  for  two  and  a  half  months. 

A    CASE    OF    RAPm    GENERAL    PARESIS    AXD    ATAXY    DEVEL- 
OPIiSG    TOGETHER. 

Thomas  J.  B.,  married,  aet.  51,  clerk,  no  insane  relatives; 
first  attack  of  insa  nit}' ;  supposed  to  depend  on  intemperance, 
although  he  had  been  temperate  for  the  last  two  years.     A 


THE    GALLOPING    FORM.  8 1 

slight  attack  of  depression,  lasting  one  week,  occurred 
when  he  became  teetotal.  He  has  had  two  severe  falls, 
with  no  symptoms  of  local  head  injury.  The  first  symp- 
toms of  this  attack  occurred  three  weeks  before  admission, 
when  he  became  strange  in  manner;  unable  to  attend  to 
his  business  ;  sleepless,  with  exaltation  of  ideas  ;  believing 
himself  a  great  man;  able  to  compose  poetry  and  paint 
pictures,  at  least,  fit  for  the  academy.  He  said  his  father 
was  the  son  of  a  nobleman;  was  restless,  boastful  and  en- 
croaching ;  constantly  moving  about,  willing  to  race  or 
fight  with  the  patients.  His  pupils  were  small  but  equal ; 
memory  for  recent  events  bad ;  walk  unsteady,  legs  be- 
ing thrown  away  from  the  body  and  falling  on  the  heels ; 
patellar  reflexes  absent,  says  he  can't  feel  the  ground  ;  falls 
on  closing  eyes  ;  slight  tremor  of  lips  and  hesitation  of 
speech.  He  continued  happy  and  contented  with  his  pow- 
ers, making  many  pictures  and  filling  reams  of  paper.  In 
about  a  month  he  had  divergence  of  eyes ;  marked  cere- 
bral giddiness  when  left  eye  was  closed ;  no  evident 
changes  visible  in  his  discs.  Since  then  bodily  and  men- 
tal weakness  progressed  rapidly.  (Abstract,  Savage  on 
Insanity,  p.  318.) 

A    CASE    OF    GALLOPING    GENERAL    PARESIS. 

A  man  of  40,  who  had  always  been  healthy,  was  taken 
ill  and  in  a  few  weeks  developed  a  typical  case  of  general 
paresis  with  well-marked  expansive  ideas  and  delusions  of 
grandeur  and  power.  He  was  removed  to  the  asylum 
and  died  there  in  ten  days  from  a  series  of  convulsive 
seizures  which  numbered  ninety-nine  in  twenty-four  hours. 
(Abstract,  Jelliffe,  Allgem.  Zeitschreift  fiir  Psych.,  55, 
99-5-) 

GENERAL  PARESIS  OF  THE  GALLOPING  TYPE. 

Louis  F.  G.,  married,  ast.  50;  artist,  no  history  of  in- 
sanity in  the  family ;  and  no  previous  attack  of  insanity. 
He  had  suffered  from  pleurisy  with  delirium  two  years  be- 
fore ;  steady  in  his  habits  ;  cheerful  and  intelligent.  Two 
months  before  admission  he  was  irritable,  nervous  and  de- 
pressed ;  he  lost  his  artistic  power  and  forgot  to  complete  his 


02  VARIETIES    OF    GENERAL    PARESIS. 

orders.  Went  from  London  to  Paris  and  was  unconscious 
of  the  difference  between  the  cities.  When  he  returned  his 
bodily  health  was  seen  to  be  failing  ;  sleepless,  poor  appetite, 
difficulty  in  swallowing.  He  was  clean  in  his  habits  ;  had 
no  extravagant  ideas.  He  could  not  recognize  himself  in 
the  glass,  was  suspicious,  violent  and  obstinate  about  his 
food.  The  diagnosis  was  general  paralysis  in  an  early 
stage.  Within  two  weeks  he  was  so  weak  as  to  have  to 
be  kept  in  bed  ;  bed-sores  developed  and  he  died  in  six 
weeks.     (Abstract,  Savage,  oj).  c/L,  p.  297.) 

The  Double  Form. — The  circular  type  of  paresis,  or 
the  double  form,  occurs  in  some  cases,  and  most  fre- 
quently where  there  is  a  history  of  heredity.  This 
does  not  refer  to  the  mental  fluctuations  after  seizures, 
or  to  ordinar}'  variability  and  emotional  disturbances, 
but  it  is  a  distinct  type,  which  characterizes  a  certain 
group  of  cases. 

The  phases  of  the  disease,  in  these  cases,  differ  so 
widely  as  sometimes  to  cause  the  physician  to  doubt 
the  diagnosis.  The  characteristic  symptoms  of  ela- 
tion, either  with  or  without  an  intermediate  period  of 
calm,  may  pass  into  a  phase  of  depression,  accom- 
panied at  times  by  delusions  of  melancholia,  even 
with  suicidal  tendencies,  and  sometimes  with  ideas 
of  persecution.  This  may  be  followed  by  a  fresh 
outbreak  of  excitement  with  violence,  or  exaltation 
and  expansive  delirium;  and  this,  again,  be  succeeded 
by  melancholia. 

The  phase  of  depression  has  been  known  to  con- 
tinue for  months,  in  this  way  prolonging  the  life  of 
the  patient,  for  the  periods  of  excitement,  naturally, 
reduce  more  quickly  the  strength  of  the  system. 

GENERAL  PARESIS  OF  THE  DOUBLE  FORM. 

In  a  patient,  exalted  mania  followed  an  attack  of  de- 
pression, resembling  circular  insanity,  but  instead  of  the 
melancholy  returning,  difficulty  in  articulation  and  epilepti- 


THE    DOUBLE    FORM.  83 

form  attacks  supervened  and  he  is  now  in  last  stage  of  the 
disease.     (Abstract,  Blandford  on  Insanity,  p.  306.) 

GENERAL  PARESIS  OF  THE  DOUBLE  FORM. 

Herbert  F.,  single,  get.  42,  accountant,  no  insane  rela- 
tives, first  attack  of  insanity,  no  cause  known.  When 
admitted  the  symptoms  had  existed  about  six  weeks. 
They  began  with  nervousness  and  twitching,  followed  by 
depression  and  threats  of  suicide,  but  were  soon  replaced  by 
great  exaltation  and  extravagance.  He  believed  himself 
rich  and  powerful  and  offered  marriage  to  several  ladies 
tongue  tremulous,  pupils  equal ;  hallucinations  of  hearing 
memory  weak,  sleeps  well ;  excessive  patellar  reflexes 
writing  shaky.  Five  weeks  after  admission,  both  legs 
swelled  and  unhealthy-looking  pustules  formed.  In  two 
months  he  was  variable,  weaker  in  mind  and  emotional. 
In  three  months  more  he  was  melancholic  and  said  he  had 
offended  God,  but  again  became  violent  and  emotional. 
In  a  3'ear  after  admission  he  was  quiet,  no  exaltation, 
looked  like  one  suffering  from  melancholia  with  stupor  ; 
circulation  feeble,  hands  livid  and  congested.  A  little  loss 
of  expression,  less  tremor  of  tongue  and  hesitation  of 
speech,  yet  he  was  wet  and  dirty.  If  seen  for  the  first 
time  now,  he  would  hardly  be  recognized  as  a  general 
paralytic.     (Abstract,  Savage,  o^.  cit.,  p.  326.) 

GENERAL    PARESIS    IN    WHICH    PARETIC    SYMPTOMS 
ALTERNATE    WITH    IDEAS    OF    PERSECUTION. 

A  hereditary  degenerative  patient  was  attacked  by  gen- 
eral paralysis.  At  about  the  same  period  manifested  ideas 
of  persecution,  and  attempted  suicide.  On  admission  in 
the  following  year  he  presented  classical  signs  of  general 
paralysis,  also  ideas  of  persecution  and  hallucinations  of 
hearing.  The  symptoms  of  meningo-encephalitis  disap- 
peared, while  delusions  of  suspicion  increased.  Psycho- 
motor hallucinatory  delusions  of  general  and  genital  sensi- 
bility were  added  and  he  attacked  his  "  persecutors"  with 
deliberate  violence.  Two  years  later  he  had  two  epilepti- 
form attacks  and  signs  of  general  paralysis  reappeared  in 


84  VARIETIES    OF    GENERAL    PARESIS. 

a  more  serious  form,  delusions  of  persecution  vanished. 
Again  the  paralytic  symptoms  retrogressed  and  the  delu- 
sions revived.  In  three  years  more  his  mental  faculties  had 
declined  in  vigor  and  the  persecutory  insanity  had  pro- 
gressively lost  in  activity  and  cohesion.  (Magnon,  Jour- 
nal of  Mental  Science,  Vol.  53,  p.  381.) 

GENERAL    PARESIS    OF    THE    ALTERNATING    FORM. 

J.  B.,  a  countr}'  laborer,  with  a  history  of  alcoholic  ex- 
cess and  hereditary  taint.  On  admission  he  was  melan- 
choly, not  inclined  to  conversation  or  to  answer  questions. 
He  had  the  delusion  that  no  one  would  employ  him  and 
was  so  miserable  that  he  secluded  himself  and  would  not 
go  out  of  doors.  He  feared  that  something  was  going 
to  happen  to  himself  and  famil}-  and  refused  food.  His 
pulse  was  120,  with  no  physical  symptoms  to  account  for 
it ;  no  nervous  phenomena ;  pupils  natural  in  size  and  out- 
line, but  sluggish ;  tongue  protruded  a  little  to  the  right 
side ;  his  general  condition,  pallor,  want  of  muscular  tone 
and  anemia.  A  curious  fact  was  that  his  despondency 
came  on  towards  evening  and  had  disappeared  by  morn- 
ing. He  did  not  sleep  well,  was  fidgety,  restless  and 
would  not  keep  in  bed.  He  was  sent  to  work  in  the 
garden,  became  more  cheerful,  less  restless  and  appeared 
convalescent,  but  two  weeks  later  was  nervous,  frightened 
and  tried  to  get  out  of  the  window  at  night.  Nervous 
twitchings  were  now  observed  around  eyelids  and  mouth ; 
his  voice,  at  first  melancholic,  was  now  emotional  and  trem- 
ulous ;  he  was  facile,  easil}'  diverted  from  one  subject  to 
another,  but  peculiarly  sensitive  in  his  feelings.  Later  the 
depression  disappeared,  he  showed  temper  and  impatience  ; 
he  was  now  reported  as  gaining  strength,  and  improved  in 
his  mental  condition,  but  twitching  around  eyes  and  mouth 
was  still  present.  He  was  discharged  much  improved  and 
again  admitted  in  three  months.  He  is  now  decidedly 
paretic,  soon  gets  tired  in  walking  and  staggers  ;  his  words 
are  interrupted  ;  there  is  a  quivering  of  the  lower  lip,  even 
when  the  mouth  is  closed.  Pupils  normal,  except  that  they 
remained  dilated  for  two  or  three  months.      He    is    now 


MELANCHOLIC    FORM.  85 

violent  and  abusive.  (Abstract,  Campbell  Clark,  Mental 
Diseases,  p.  217.) 

General  Paresis  of  the  Melancholic  Form. — One  of  the 

types  of  general  paresis,  first  described  by  Baillarger, 
is  that  with  symptoms  of  melancholia  and  h3-pochon- 
dria.  In  the  place  of  the  symptoms  of  elation  in  the 
first  stage,  there  is  a  feeling  of  anxiety  and  forebod- 
ing. In  these  cases  it  is  more  than  a  passing  feeling 
of  depression  of  spirits,  which  is  so  frequent  in  the 
prodromal  stage.  The  symptoms  are  so  like  those 
of  a  true  melancholia  that  the  history  presented  by 
the  friends  of  the  patient  must  greatly  influence  the 
diagnosis,  until  such  time  as  a  congestive  attack,  or 
some  somatic  sign,  occurs  to  give  assurance  as  to  the 
nature  of  the  malady.  After  a  time,  in  some  cases,  the 
ordinary  course  of  the  disease  is  followed,  in  others 
the  symptoms  of  mental  depression  persist  to  the  end. 

The  hypochondriacal  form  of  the  disease  is  marked 
by  headache,  defective  circulation,  vaso-motor  dis- 
turbances and  various  abnormal  sensations,  referred 
chiefl}-  to  the  internal  organs.  Associated  therewith 
are  the  mental  conditions  of  despondency,  languor, 
inattention  and  distress  about  unimportant  matters. 
Actual  pain  in  the  epigastric  region  may  be  com- 
plained of  for  some  time,  indicating,  as  some  believe, 
an  involvement  of  the  great  sympathetic  nerve.  Hal- 
lucinations and  illusions  of  a  disagreeable  character 
are  sometimes  added  to  the  other  symptoms. 

Clouston  believes  that  almost  all  of  these  patients 
suffer  from  some  organic  visceral  disease,  or  func- 
tional disturbance,  which  transmits  sensations  that 
are  disagreeable  and  depressing.  In  examining  his 
pathological  register,  he  found  that  nearly  all  ot  his 
cases  of  general  paresis  who  had  had  tubercular 
disease  had  been  melancholic. 


86  VARIETIES    OF    GENERAL    PARESIS. 

A    CASE    OF    THE    MELANCHOLIC    FORM    WITH    TUBERCULAR 

DISEASE. 

G.  K.,  a  man,  had  the  fixed  melancholic  delusion  that 
a  man  was  inside  of  him,  who  annoyed  him  constantly  and 
thus  made  him  depressed.  Death  showed  tubercular  dis- 
ease of  the  intestines.  (Abstract,  Clouston,  Mental  Dis- 
eases, p.  400.) 

A    CASE    OF     THE     MELANCHOLIC    FORM    WITH    BRONCHITIS. 

A  cabman  who  was  very  happ}-  in  the  supposed  posses- 
sion of  thousands  of  pounds  suddenly  became  melancholic, 
declared  himself  a  beggar  and  cried  bitterly.  Upon  exam- 
ination he  was  found  to  be  suffering  from  bronchitis. 
Reflex  action  was  so  dulled  that  he  had  no  cough  and  felt 
no  pain.  As  he  improved  his  delusions  of  grandeur  re- 
turned ;  upon  relapse  the  melancholy  state  at  once  came 
back,  but  at  last  he  recovered  from  the  bronchitis  and  was 
again  the  happy  possessor  of  his  thousands  (Clouston). 
The  author  adds:  "Whenever  I  see  a  general  paretic 
dull,  now  I  always  search  for  an  organic  visceral  cause 
and  usually  find  it." 

GENERAL    PARESIS   OF    THE    MELANCHOLIC    FORM. 

The  patient  never  presented  symptoms  of  excitement  or 
exhilaration  before  admission,  and  since  then  the  mental 
state  has  been  one  of  depression  ;  he  sees  people  at  night 
climbing  into  the  window  or  door  of  his  room;  they  are 
his  enemies  and  try  to  take  pictures  of  him.  At  other 
times,  they  pound  his  feet  black  and  blue  and,  in  evidence, 
he  begs  you  to  examine  them  for  yourself.  At  other 
times,  he  hears  them  shouting  to  him  to  come  out  and  de- 
fend himself  if  he  can.  He  believes  they  are  the  attend- 
ants, who  disguise  themselves  at  night,  and  says  he  would 
kill  them  if  he  could,  and,  in  fact,  he  tries  to  whenever  he 
gets  a  chance.  He  had  an  epileptoid  seizure  soon  after 
admission  and  was  in  a  partial  hemiplegic  condition  for 
nearly  three  weeks.  (iVbstract,  Stearns,  Mental  Diseases, 
p.  484.) 


MELANCHOLIC    FORM.  87 

A    CASE    OF    GENERAL    PARESIS    OF    THE    MELANCHOLIC 

TYPE. 

John  C,  married,  aged  47,  merchant;  no  insane  relatives. 
First  attack  of  insanity,  which  had  lasted  six  weeks, 
caused  by  loss  of  money,  and  anxiety,  and  began  with  the 
loss  of  identity.  He  refused  to  take  food  because  he 
believed  he  could  not  afford  it,  and  because  he  thought 
people  were  trying  to  poison  him ;  after  admission, 
he  was  reported  as  silent  and  obstinate,  refusing  his  food, 
negligent  of  his  person  and  sleepless  ;  he  had  to  be  fed  arti- 
ficially ;  and  he  had  a  convulsive  seizure  in  the  early  part 
of  his  illness.  He  slowly  lost  strength,  but  remained  per- 
verse and  melancholy.  The  cause  of  his  physical  deteri- 
oration and  of  the  difficulty  in  breathing  which  came  on, 
was  unknown.  Died  in  about  three  months.  (Abstract, 
Savage,  o^,  cit,,  p.  314.) 

AN    ODD    CAPRICE    IN    A    MELANCHOLIC    PARETIC. 

A  patient,  prevented  from  suicide  by  his  wife,  drew  dia- 
grams of  his  tombstone,  whose  inscription  recited  all  his 
achievements,  and  sang  the  praises  of  his  wife  for  saving 
the  life  of  so  valuable  a  citizen.  (Abstract,  Spitzka  on 
Insanity,  p.  199.) 

A  PECULIAR    DELUSION    OF  ONIONS    AND    SARDINES,   IN    THE 
HYPOCHONDRIACAL    TYPE. 

A  patient  who  could  not  eat  or  digest,  and  who  had  not 
a  penny,  according  to  his  statements  made  during  the  hy- 
pochondriacal period,  awoke  one  morning  with  the  project 
to  get  up  a  monopoly  of  the  entire  sardine  and  Bermuda 
onion  trade  in  the  world,  and  having,  as  he  alleged,  se- 
cured it,  proposed  to  eat  all  the  sardines  and  onions  him- 
self.    (Abstract,  Spitzka,  op.  cit.,  p.  200.) 

A  CASE  OF  GENERAL  PARESIS  OF  THE  MELANCHOLIC  TYPE. 

One  patient  who  had  many  of  the  commonest  delusions 
of  melancholia,  thought  he  was  going  to  be  arrested,  that 
people  were   going  to  injure   him,  that  they  were  malign- 


88  VARIETIES    OF    GENERAL    PARESIS. 

ing  and  going  to  rob  him.  Yet  he  was  not  melancholic 
as  other  men  were.  He  never  refused  his  food,  but  was 
very  fond  of  it,  and  ver}'  particular  as  to  what  he  ate.  He 
had  a  good  opinion  of  himself,  very  vain  of  his  personal 
appearance,  and,  with  all  his  melancholy  ideas,  was  often 
quite  cheerful  and  chatty.  His  mind  was  dull,  lethargic 
and  void  of  excitement  during  the  whole  illness.  (Ab- 
stract, Blandford,  of.  ciL,  p.  289.) 

Spinal  General  Paresis. — There  are  several  groups  of 
cases  termed  the  spinal  varieties  of  the  disease,  in 
which  there  are  various  implications  of  the  cord. 
Only  to  a  limited  degree  should  they  be  looked  upon 
as  ascending  and  descending  systemic  affections,  but 
rather  as  general  diffuse  affections  depending  upon 
the  involvement  of  the  whole  nervous  system.  It  is 
not  strange,  therefore,  when  we  consider  that  the 
process  of  degeneration  is  one  affecting  the  entire 
nervous  tissues  that  in  a  certain  proportion  of  the 
cases  the  form  of  the  disease  should  be  first  mani- 
fested in  some  portion  of  the  spinal  cord. 

Bevan  Lewis  ^  has  divided  the  cases  of  general 
paresis  as  the}-  relate  to  the  cord  into  three  varie- 
ties: (i)  In  a  majority  of  the  cases,  as  the  only 
evidence  of  spinal  implication,  we  find  diminished 
cutaneous  sensibility  and  sluggish  knee-jerk,  alternat- 
ing at  a  later  period  with  increased  knee-jerk,  usually 
as  the  direct  sequel  to  a  congestive  seizure.  Later  in 
the  disease  paretic  symptoms  may  preponderate,  but 
the  cerebral  implication  throughout  is  always  the 
more  emphasized.  (2)  The  tabetic  group,  with  most 
of  the  symptoms  of  tabes  dorsalis.  Yet  we  usu- 
ally witness  complete  subsidence  of  the  special 
spinal  S3'mptoms  when  the  full  development  of  the 
cerebral  symptoms  is  established;  or  what  is  not 
infrequent  the    anesthesia    and    ataxy    may   even  be 

'O/.  cit.,  p.  556. 


SPINAL  FORM  OF  GENERAL  PARESIS. 


SPINAL    GENERAL     PARESIS.  89 

replaced  by  spastic  paraplegia.  (3)  The  group  of 
spastic  cases  in  which  symmetrical  descending  scle- 
rosis of  the  lateral  columns  is  early  apparent  and 
continuous;  usually  as  the  sequel  of  convulsive 
seizures  and  especially  frequent  in  those  subjects  who 
have  been  addicted  to  alcoholic  excess. 

The  best  observers  have  invariably  failed  to  find 
that  the  great  Wallerian  law  of  degeneration  applies 
to  the  pathological  reductions  of  general  paresis.^ 

IMPLICATION    OF    THE    LATERAL    COLUMNS. 

Francis  R.,  single,  aged  30,  medical  student,  no  history 
of  insanity,  first  attack,  lasting  six  months;  said  to  have 
followed  excesses  and  to  have  had  former  attack  of  syphilis. 
The  first  symptoms  were,  change  in  disposition,  oddness 
in  behavior  and  absence  of  mind.  He  had  always  been 
vain  about  his  appearance  and  powers  and  this  developed 
into  extreme  exaltation  ;  he  thought  himself  a  perfect  para- 
gon, although  he  had  not  passed  even  his  preliminary  exam- 
ination. On  admission  he  was  of  medium  height,  squarely 
built,  with  bright  malar  capillary  congestion,  his  walk 
jerky,  patellar  reflexes  exaggerated,  pupils  unequal,  the 
right  one  larger,  both  reacting  to  accommodation,  but 
slightly  only  to  light.  For  twelve  months  he  slowly  devel- 
oped weak-mindedness,  great  hesitation  in  speech,  extreme 
facial  and  lingual  tremor,  a  nervously  irritable  appear- 
ance ;  no  control  over  bladder  and  rectum ;   indifferent  to 

^  One  of  the  earlier  views  of  paretic  dementia,  when  it  was  the  termi- 
nation clinically  of  posterior  sclerosis,  was  that  the  degenerative  conditions 
in  the  spinal  cord  continued  through  the  motor  tracts  all  the  way  to  the 
cerebrum  and  to  the  cerebral  cortex.  This  is  certainly  not  the  correct 
view.  A  number  of  years  ago  I  had  for  several  years  a  case  of  posterior 
sclerosis  under  my  care  in  private  practice.  The  patient  became  paretic 
and  went  to  the  Pennsylvania  Hospital  for  the  Insane,  and  subsequently 
to  Danville,  where  he  died.  The  body  was  sent  to  Philadelphia,  and  a 
post-mortem  was  made,  and  twenty  or  thirty  sections  from  the  cord,  and 
all  the  way  to  the  cortex,  were  examined  under  the  microscope.  Similar 
cases  have  been  recorded.  The  disease  perhaps  ascends  so  far  as  the  cord 
is  concerned;  but  the  cerebral  condition  is  only  a  localized  expression  of 
a  general  condition.  The  disease  does  not  usually  extend  anteriorly  beyond 
the  oblongata  and  pons.  (Mills,  C.  K.,  Nervous  and  Mental  Diseases,  Vol. 
18,  p.  85.) 


go  VARIETIES    OF    GENERAL    PARESIS. 

his  surroundings,  neither  reading  nor  associating.  One 
year  after  admission  he  was  unable  to  walk  alone,  could 
not  articulate  a  single  word,  very  wet  and  dirty,  legs  be- 
coming contracted.  He  died  in  about  three  years  after 
onset  of  disease.     (Abstract,  Savage,  op.  ciL,  p.  319.) 

GENERAL    PARESIS    WITH    LATERAL    SCLEROSIS 
IN    A    WOMAN. 

Edith  C,  married,  ast.  35,  printer's  wife,  no  history  of 
insanity,  lirst  attack,  of  six  weeks'  duration,  had  no  chil- 
dren. When  admitted  the  first  symptoms  were  accusations 
against  her  husband.  She  became  incoherent  and  restless, 
wandering  about  in  her  night-dress,  saying  her  husband 
wanted  to  poison  her ;  she  was  excited,  had  exalted  ideas 
about  riches ;  thought  there  was  chloroform  in  her  hus- 
band's brain,  that  he  was  mad;  that  she  was  a  duchess. 
On  admission  she  had  hallucinations  of  taste,  pupils  small 
but  equal,  slept  badly,  walk  shaky,  reflexes  greatly  exag- 
gerated, no  change  in  optic  discs.  After  admission,  she 
steadily  got  more  feeble  in  gait,  more  tremulous  in  speech, 
with  difficulty  in  swallowing,  and  loss  of  power  over  rec- 
tum and  bladder.  In  about  two  months  she  had  an  epi- 
leptiform attack  with  general  convulsions,  but  the  symp- 
toms were  most  marked  on  right  side  ;  she  lost  power  and 
sank.     (Abstract,  Savage,  oj).  ci'L,  p.  320.) 

IMPLICATION    OF   POSTERIOR   COLUMNS.      GENERAL  PARESIS 
PRECEDED    BY    LOCOMOTOR    ATAXIA. 

G.  A.,  a  man  of  50,  who  had  had  locomotor  ataxia  for 
seven  years,  began  to  be  maniacal,  sleepless,  and  to  have 
delusions  of  grandeur.  Imagined  he  was  an  earl  wath 
millions ;  wrote  fifty  letters  a  day,  ordering  everything 
imaginable  ;  and  invited  the  Queen  to  dinner.  His  speech 
was  affected  by  the  characteristic  tremble  of  the  lips,  the 
shuffle  and  thickness  in  the  articulation  of  long  words  and 
sentences.  He  passed  through  the  second  and  third 
stages  of  the  disease  and  died  in  eighteen  months  from 
the  time  of  the  beginning  of  the  mental  symptoms. 
(Abstract,  Clouston,  op.  c/L,  p.  389.) 


SPINAL    GENERAL     PARESIS. 


91 


Fig.  I. 


GENERAL  PARESIS  FOLLOWING  LOCOMOTOR  ATAXIA. 

A  chaplain  in  a  Welsh  prison  had  locomotor  ataxia  of 
very  marked  and  progressive  character.  He  kept  his  ap- 
pointment in  the  prison  for  several  years.  After  ten  years, 
he  showed  signs  of  exaltation.  These  became  progres- 
sive, he  began  to  run  down  rapidly,  went  into  general 
paralysis  and  died  eighteen 
months  after  the  latter  symp- 
toms developed.  (Abstract, 
Down,  Transactions  of  Ninth 
International  Medical  Con- 
gress, Vol.  5,  p.  405.) 

GENERAL  PARESIS  FOLLOW^ING 
LOCOMOTOR  ATAXIA. 

A  patient  having  locomotor 
ataxia  finally  showed  mental 
symptoms  in  the  form  of  ex- 
citement and  delusions  of  gran- 
deur. No  mental  symptoms 
had  appeared  until  a  year  after 
the  motor  symptoms,  but  there 
had  been  mental  weakness  for 
some  time  prior  to  the  appear- 
ance of  the  more  pronounced 
mental  symptoms.  (Abstract, 
Stearns,  0^.  cit.,  p.  513.) 

GENERAL    PARESIS    OF    THE 


TABETIC    FORM. 


c. 

dier, 
three 


B.,  aet.  39,  married,   sol-  station  in  tabetic  form  of  gen- 
father    was    insane    for     ,,     .     ;^^-^  ^--^sis. 

Showing  tendency  to  over-extensiou 

months.         History       of    of  the  knee-joint;  needing- aid  of  both 

,  -r  T  ,      y  ,     sight  and  supportto  maintain  balance. 

present  attack  :    unsettled,  and 

could  not  fix  attention  on  his  work,  did  stupid  things  in  the 
house ;  although  wife  and  children  were  starving,  spent 
what  money  he  had  in  useless  articles  and  gave  large 
orders  for  things  for  which  he  could  not  pay.  On  admis- 
sion, imagined  he  was  very  wealthy.     He  was  restless, 


92  VARIETIES    OF    GENERAL    PARESIS. 

talkative  and  excited ;  he  could  not  sleep  at  night,  owing 
to  imaginary  insects  annoying  him  (hallucination  of  touch). 
His  left  pupil  larger  than  right,  both  reacting  to  light ; 
tongue  tremulous ;  sensation  normal ;  reflexes  not  im- 
paired ;  special  senses  healthy.  Progress  of  case  :  Exal- 
tation well  marked,  says  he  is  a  magnificent  writer,  while 
in  reality  he  can  barely  write  his  own  name.  There  is 
considerable  mental  enfeeblement,  articulation  correct, 
tongue  tremulous ;  left  pupil  sometimes  larger  and  some- 
times smaller  than  the  right ;  outline  sometimes  irregular. 
There  are  tabic  symptoms.  Standing  with  feet  together 
and  eyes  shut,  he  sways  about  and  tends  to  fall.  A  year 
after  admission  :  Mild  exaltation,  showing  itself  in  con- 
tented expression,  and  not  in  well-marked  delusions  ;  no 
excitement  or  depression.  Enfeeblement  is  well  marked, 
seen  in  being  easily  controlled,  in  want  of  self-assertion, 
in  absence  of  mental  vigor ;  memory  is  impaired,  espe- 
cially for  names  of  places. 

The  symptoms  of  locomotor  ataxia  are  well  marked. 
With  his  eyes  open,  has  difficulty  in  walking  and  cannot 
stand  unsupported ;  his  lower  limbs  little  better  than  arti- 
ficial limbs  ;  coordination  of  arms  and  hands  not  impaired. 
Sensation  to  pain  and  tovich  impaired  in  lower  extremities, 
much  less  so  in  upper;  plantar  reflex  impaired,  tendon 
reflex  abolished,  right  pupil  larger  than  left,  contract  to 
accommodation  but  not  to  light.  (Abstract,  Campbell 
Clark,  of.  c/'t.,  p.  219.) 

A    CASE     OF     GENERAL    PARESIS     FOLLOWING     LOCOMOTOR 
ATAXIA    OF    SYPHILITIC     ORIGIN. 

Alfred  S.,  single,  45  ;  no  neurotic  history;  syphilis  six- 
teen years  ago,  but  no  serious  secondary  troubles.  Six 
years  ago  locomotor  ataxy  developed  and  was  treated. 
Symptoms  of  mental  disorder  have  appeared  during  the 
past  week.  He  had  been  exposed  to  wet  and  cold  a  good 
deal  recently.  He  became  excitable  and  irritable  and 
sleepless  and  noisy  at  night.  He  wrote  endless  letters, 
tore  up  books ;  w^as  going  to  reform  the  world,  to  suppress 
the  House  of  Commons,  to  blow  up  everything  with  dyna- 


SPINAL    GENERAL     PARESIS.  93 

mite.  He  has  had  hallucinations  of  hearing  for  a  month, 
and  shooting  pains  in  his  legs.  He  had  frequent  erec- 
tions and  emissions;  pupils  at  times  equal,  small  at  others, 
the  left  larger.  Six  years  ago  he  had  convergence  and 
diplopia,  cured  by  the  use  of  mercury:  general  and  color 
vision  normal ;  pupils  reacting  both  to  light  and  accommo- 
dation ;  patellar  reflexes  absent;  walk  ataxic.  On  ad- 
mission, he  had  all  the  most  marked  symptoms  of  ataxia 
and  of  general  paralysis  of  the  insane  and  no  treatment 
seemed  in  any  wav  to  affect  him.  (Abstract,  Savage, 
Transactions  of  Ninth  International  INIedical  Congress, 
Vol.  5,  p.  939.) 

TWO   JUVENILE    CASES     IX    WHICH    THE    FIRST    MANIFESTA- 
TIONS   OF    THE    DISEASE    WERE    IN    THE    CORD. 

Female,  ast.  23,  ill  two  vears,  in  a  helpless  condition, 
unable  to  walk  or  stand  up,  with  violent  tremors,  marked 
affection  of  speech,  inequality  of  pupils  and  Argyll-Rob- 
ertson phenomenon,  demented,  loss  of  control  of  bladder 
and  rectum,  marked  general  anesthesia  and  slow  re- 
flexes, suggesting  medullary  lesion.  Also  a  youth,  aged 
19,  ill  on  and  off  for  four  years,  finalh'  went  under  Char- 
cot with  paraplegia,  leading  to  a  diagnosis  of  "  organic 
lesion  of  cord."  Under  ergot  and  actual  cautery,  the  para- 
plegia disappeared,  but  later  there  was  anesthesia  of  the 
face  and  arms.  Then,  rapidly  appeared,  weakness  of 
legs,  emaciation,  affection  of  speech,  tremor  of  lips,  un- 
equal and  inactive  pupils,  wet  and  dirty  habits,  etc.,  and 
early  death  with  post-mortem  evidence  of  general  paralysis 
(Joffroy). 


CHAPTER   VIII. 
VARIETIES  [continued^. 

General  Paresis  with  Simple  Progressive  Dementia. — 
Some  cases  exhibit  simple  weak-mindedness  through- 
out the  whole  course  of  the  disease,  without  any  inter- 
mediate stages  of  excitement  or  depression.  This  may 
follow  in  cases  beginning  with  convulsions,  or  it  may 
develop  without  any  appreciable  cause.  There  is  con- 
siderable variation  in  the  manifestations.  It  may  show 
itself  in  simple  loss  of  memory,  in  an  inability  on  the 
part  of  the  patient  to  adjust  himself  to  his  surround- 
ings, or  in  a  childish  or  emotional  disturbance.  Some 
cases  are  querulous  or  nervous,  others  are  boyishly 
frolicsome.  The  ph3'sical  symptoms  take  the  usual 
course. 

GENERAL    PARESIS    OF    THE    DEMENTED    TYPE. 

G.  C,  aet.  50,  a  quiet-living  man.  First  showed  irresolu- 
tion, want  of  keen  interest,  and  forgetfulness ;  he  could  not 
realize  necessity  for  working  in  order  to  live,  and  became 
irritable  when  pressed  to  work.  Then  his  mind  showed 
clear  signs  of  enfeeblement  and  facility.  He  would 
believe  silly  stories  ;  could  not  converse  connectedly,  had 
few  likes  or  dislikes.  His  speech  was  thick,  and  lips 
quivered  when  he  began  to  speak.  His  walk  was  not 
firm  ;  in  trying  to  turn  around  sharply  he  did  so  uncer- 
tainly, and  could  not  walk  on  a  chalk  line,  or  stand  steadily 
on  one  leg.  Nearly  all  his  symptoms  are  negative.  He 
had  a  gentle  kleptomania ;  he  would  automatically  fill  his 
pockets  with  acorns,  rags,  etc.,  and  did  not  seem  to  care 
when  they  were  taken  from  him.  He  died  in  six  years  of 
pure  exhaustion,  absolutely  paralyzed,  not  having  made 
an  articulate  sound  for  a  year,  and  not  having  voluntarily 

94 


SIMPLE     PROGRESSIVE     DEMENTIA.  95 

used  a  voluntary  muscle,  lying  on  a  water  bed  and  lead- 
ing a  merely  vegetative  life.  Such  cases  are  apt  to  live  a 
long  time ;  they  are  not  usually  caused  by  a  dissipated  or 
excited  life,  and  are  of  a  calm,  phlegmatic  temperament. 
(Abstract,  Clouston,  Mental  Diseases,  p.  391.) 

A    CASE    OF    GENERAL    PARESIS    OF    THE    DEMENTED    TYPE 
WITH    EPILEPTIFORM    CONVULSIONS. 

A  traveling  salesman  was  regarded  in  good  health,  until 
his  return  home  on  one  occasion,  when  he  appeared  dazed 
and  unable  to  give  an  account  of  himself,  except  that  he  had 
been  robbed  in  a  sleeping  car  in  New  York.  It  was  then 
found  that  he  could  not  tell  an  occurrence  ten  minutes  after 
it  was  past.  On  admission,  he  was  good-natured,  facile 
and  satisfied.  He  did  not  mind  remaining  as  long  as  we 
should  choose,  though  he  left  a  sick  wife  and  little  daugh- 
ter dependent  on  friends  for  support.  No  impairment  of 
gait ;  never  had  been  excited,  was  eminently  quiet,  good- 
natured  and  satisfied.  He  had  epileptiform  convulsions, 
defective  articulation,  placid  expression  of  face,  impaired 
memory  and  weakening  mind  and  entire  satisfaction ; 
muscular  twitching  of  face  and  tongue,  but  hands  and 
legs  were  firm  and  he  walked  without  difficulty.  He  had 
a  convulsion  once  a  month  and  finally  died  from  the  effects 
of  one,  having  never  been  excited,  depressed  or  emotional. 
(Abstract,  Stearns,  Mental  Diseases,  p.  489.) 

A  CASE  OF  GENERAL  PARESIS  OF  THE  DEMENTED  TYPE 
WITH  HEMIPLEGIA. 

W.  B.,  aged  32,  father  has  had  apoplexy;  patient  had 
left  hemiplegia  of  which  a  faint  trace  remains  in  the  left 
leg ;  fairly  good  personal  history.  The  attack  of  hemi- 
plegia came  on  when  he  was  at  work  in  a  coal  pit,  but  he 
was  able  to  walk  home  though  his  leg  was  somewhat  stiff. 
His  speech  became  slow  and  thick ;  he  became  weak  and 
childish,  this  mental  change  being  noticed  before  the  onset 
of  the  hemiplegia.  The  pupils  were  at  an  early  stage 
unequal  and  the  reactions  impaired.  There  is  slight  facial 
deficiency,   tremor  of  tongue,    slight  tremor  of  lips   and 


96  VARIETIES    OF    GENERAL    PARESIS. 

he  exhibits  other  nervous  symptoms  of  general  paralysis. 
This  is  a  very  slow  case,  childish  contentment,  no  real 
exaltation.  (Abstract,  Campbell  Clark,  Mental  Diseases, 
p.  220.) 

A    CASE    OF    GENERAL    PARESIS    OF    THE     DEMENTED    TYPE 
OF    SYPHILITIC    ORIGIN. 

Patient  male  ;  ast.  45  ;  tailor.  Family  history  negative  ; 
syphilis.  Patient  first  noticed  some  weakness  in  his  left 
hand,  which  gradually  developed  into  a  paresis,  so  that  he 
could  not  carry  on  his  work.  Paresis  gradually  show^ed 
itself  in  his  left  leg.  Examination  shows  left  hemiplegia, 
with  marked  intention  tremor,  with  paralysis  agitans  of 
left  hand  ;  reflexes  exceedingly  exaggerated  ;  expression- 
less face ;  fine  tremor  of  face  and  tongue  ;  speech,  slow 
and  clumsy,  with  inability  to  pronounce  "truly  rural," 
etc.  ;  no  delusions  of  grandeur,  etc.,  but  some  slight  de- 
mentia and  contentment  with  his  condition.  (Fisher,  E. 
D.,  Journal  of  Nervous  and  Mental  Diseases,  Vol.  18,  p. 
825.) 

A    CASE    OF    GENERAL   PARESIS  WITH  SIMPLE    PROGRESSIVE 

DEMENTIA. 

E.  M.,  married,  cet.  46,  merchant,  no  insane  relatives, 
mother  died  paralyzed,  one  brother  died  of  apoplexy. 
This  was  the  first  attack ;  cause,  great  money  losses  and 
anxiety  about  his  family.  He  had  been  temperate  and 
hard-working  ;  he  had  a  convulsive  seizure  two  and  a  half 
years  before  he  was  considered  insane.  The  present  ill- 
ness began  with  incoherence  and  confusion  of  thought  and 
speech ;  he  was  unable  to  enter  into  rational  conversation, 
and  had  a  vacant  expression  of  face.  On  admission,  he  was 
stout  and  expressionless,  with  feeble  power  of  reaction  and 
negligent  of  his  personal  appearance  ;  optic  discs  greatly 
atrophied ;  reflexes  exaggerated  ;  and  nearly  all  the  mus- 
cles, both  of  face  and  limbs,  unduly  irritable  to  the  elec- 
tric current.  He  improved  bodily,  gaining  fourteen  pounds 
in  seven  months  but  mentally  became  weaker;  right  pupil 
large,    and   reacted   to   accommodation   but   not  to   light ; 


JUVENILE    GENERAL    PARESIS.  97 

great  tremor  of  facial  muscles  and  hesitation  in  speech. 
Athough  gradually  getting  weaker  in  mind,  at  times  he 
brightened  up,  and  could  recognize  relatives  and  under- 
stand his  position  as  a  patient  in  an  asylum.  Such  periods 
are  often  followed  by  convulsions  or  exaggeration  of  men- 
tal weakness.  In  two  and  a  half  3'ears  he  had  become 
ver}''  thin,  and  there  was  contraction  of  his  legs  and  he 
was  unconscious  most  of  the  time.  At  the  end  of  another 
month  he  had  a  series  of  severe  epileptiform  fits  and  died. 
(Abstract,  Savage  on  Insanity,  p.  312.) 

Juvenile  General  Paresis. — General  paresis  in  early 
life,  i.  e.,  under  the  age  of  twent}",  is  very  rare  and 
no  cases  of  it  are  to  be  found  in  medical  writings, 
until  within  very  recent  3'ears.  Most  of  the  cases 
have  been  repoi'ted  by  English  and  German  observ- 
ers, although  a  few  are  to  be  found  in  French  and 
Russian  literature.  This  form  of  the  disease  has 
been  variously  termed  developmental,  premature, 
early,  precocious,  and  juvenile  general  paresis. 

Clouston-^  gives  an  account  of  two  girls  placed 
under  his  care  in  1890.  He  says  that  in  both,  the 
first  symptoms  of  the  disease  had  been  manifest  at 
fifteen  years  of  age,  and  that  both  followed  the  usual 
course  till  they  died,  one  at  seventeen,  the  other  at 
twenty.  Both  were  undeveloped  in  form  and  appear- 
ance, neither  had  ever  menstruated,  and  both  suffered 

^  As  regards  the  occurrence  of  general  paralysis  at  this  period  of  life  of 
which  Dr.  Wiglesworth  speaks  (puberty),  I  admit  I  was  extremely  skeptical 
of  the  first  case.  One's  whole  ideas  of  general  paralysis  were  contrary  to 
its  occurrence  taking  place  at  this  earh'  period  of  life.  I,  along  with  Dr. 
Maudsley,  had  attached  very  great  importance  to  sexual  excess  in  the 
causation  of  general  paralysis  ;  and  here  we  had  cases  where  undoubtedly 
there  had  been  nothing  of  the  kind  in  any  shape  or  form.  Then  it  seemed 
extraordinary  that  every  other  possible  cause  of  general  paralysis  was 
absent,  in  these  particular  cases.  On  the  whole  it  had  the  effect  on  my 
mind  of  almost  revolutionizing  my  ideas  of  general  paralysis.  To  begin 
with  there  were  great  doubts  expressed  as  to  whether  they  were  cases  of 
general  paralysis  or  not ;  but  I  think  the  evidence  is  so  striking,  and  in 
Dr.  Wiglesworth's  paper  it  is  of  so  conclusive  a  nature  that  such  cases  will 
not  be  questioned  in  the  future.  (Clouston,  Journal  of  Mental  Science, 
18930 


98  VARIETIES    OF    GENERAL    PARESIS. 

from  hereditary  neuroses,  and  hereditary  syphilis. 
The  pathological  appearances  found  in  the  brains  of 
both,  together  with  the  symptoms  during  life,  left  no 
doubt  as  to  the  nature  of  the  disease. 

In  almost  all  cases  there  are  premonitory  symptoms 
in  a  change  of  disposition,  a  loss  of  interest  in  sur- 
roundings, diminished  energy,  morbid  sensitiveness 
or  some  other  mental  change  marking  a  weakened 
nervous  energizing.  Delusions  of  grandeur  are 
seldom  present,  and  far  the  larger  number  affected 
are  girls. 

The  disease  occurs  as  one  of  the  groups  of  the 
neuroses  of  development,  and  subjects  are  usually 
possessed  of  a  family  history  of  neuroses,  insanity 
and  frequently  syphilis. 

A    CASE    OF    GENERAL    PARESIS    OF    THE    JUVENILE    TYPE. 

A  female  child,  aet.  13,  ten  months  ago  became  dull  in 
mind.  During  the  course  of  the  case  she  had  several  falls 
and  hurt  herself,  but  it  was  noticed  that  she  was  dull  before 
she  had  the  falls  :  she  was  the  tifth  child  of  her  parents  ; 
the  four  previous  children  are  alive  and  healthy.  Subse- 
quently to  the  patient's  birth,  two  pregnancies  ended  re- 
spectively in  a  still-birth  and  miscarriage.  When  seen,  she 
presented  tvpical  physical  signs  of  general  paresis.  Her 
father  died  with  paralytic  symptoms  attributed  to  syphilis 
and  the  mother  died  a  year  later  with  similar  symptoms. 
The  patient  was  not  conscious  of  being  ill ;  she  said  she 
was  always  happv.  (Abstract,  Norman,  Journal  of  Mental 
Science,  Vol.  39,  p.  307.) 

A  CASE  OF  GENERAL  PARESIS  IN  THE  ADOLESCENT  PERIOD. 

J.  McC,  aet.  19,  both  parents  very  intemperate  ;  patient 
naturally  weak-minded,  but  had  been  to  school ;  fifteen 
months  before  admission  he  had  a  fall  on  his  head  and  lay 
unconscious  for  four  days  in  convulsions  :  was  said  never 
to  have  fully  recovered  his  mind  after  this.  On  admission 
he  was  in  a  condition  of  advanced  dementia.     He  could  not 


PUte  VL 


JUVENILE  GENERAL  PARESIS. 

A  case  of  the  Juvenile  Form  recently  under  observation  for  a  time  at  tVie  Philadelphia 
Hospital.  The  patient  was  taken  from  the  Institution  and  afterwards  disc.ppeared  from 
view.     From  a  photograph  kindly  loaned. 


JUVENILE    GENERAL    PARESIS.  99 

answer  a  single  question  rationally ;  excited  and  noisy ; 
muttering  an  incoherent  jargon ;  wet  and  dirty.  Died  in 
six  months.  (Abstract,  Wiglesworth,  Journal  of  Mental 
Science,  Vol.  39,  p.  357.) 

A    CASE     OF    GENERAI.    PARESIS     OF    THE    JUVENILE    TYPE. 

M.  E.  M,,  girl,  aet.  15,  parents  healthy  and  temperate, 
father  aged  50,  mother  42,  had  been  married  eighteen 
years.  The  patient  was  the  second  child  in  the  family; 
she  was  one  of  three  survivors  out  of  thirteen  pregnancies, 
and  of  the  eight  female  pregnancies  patient  was  the  only 
survivor.  Two  of  the  others  were  miscarriages,  two  were 
still-born,  one  died,  aged  two  weeks,  and  the  other  two  died 
of  scarlatina.  Of  the  five  male  pregnancies,  one  died, 
aged  five  weeks,  in  a  fit,  one  aged  two  of  some  unknown 
cause,  another  aged  two  and  a  half  years  of  scarlatina. 
There  was  no  other  evidence  of  syphilis,  but  the  above 
suggests  it.  No  history  of  nervous  disease  in  the  family. 
Patient  was  bright  until  eleven  years  old,  when  she  fell, 
striking  her  head ;  unconscious  for  two  hours  and  in  bed 
with  headache  for  several  days.  Some  months  after,  she 
developed  weakness  of  the  limbs.  A  year  after  accident 
she  was  noted  to  be  getting  dull,  losing  her  memory,  and 
from  that  time  on  her  mind  gradually  faded  away.  During 
three  or  four  years  previous  to  admission  she  had  several 
falls,  apparently  the  result  of  paresis  ;  once,  she  fell  down 
a  whole  flight  of  stairs  and  had  convulsions  during  the 
following  night.  On  admission  intelligence  very  defective. 
Answers  "I  don't  know"  to  all  questions  ;  powers  of  atten- 
tion and  understanding  deficient ;  unable  to  look  after  her- 
self ;  inattentive  to  the  calls  of  nature  and  sometimes  noisy. 
A  well  developed  child,  signs  of  puberty  slightly  marked  ; 
had  never  menstruated ;  pupils  slightly  dilated  and  of 
normal  reaction ;  viscera  were  sound ;  considerable  de- 
mentia ;  usually  quiet  and  tractable ;  took  no  interest  in 
her  surroundings ;  when  touched,  however,  cried  and 
seemed  frightened :  much  loss  of  memory  and  could 
answer  correctly  only  the  simplest  questions ;  wet  and 
dirty  in  her  habits.    After  three  months  she  was  sent  home 


lOO  VARIETIES    OF    GENERAL    PARESIS. 

in  the  same  condition  ;  readmitted  five  months  later  a  com- 
plete wreck,  mentally  and  physically ;  could  not  stand 
alone,  could  not  tell  her  own  name,  seemed  to  understand 
nothing  that  was  said  to  her.  Continually  moved  to  and 
fro  in  her  chair,  uttering  a  crowing  meaningless  laugh  and, 
when  touched,  she  cried  loudly  and  continuously  ;  tongue 
tremulous,  also  lips ;  speech  hesitating  and  ejaculatory ; 
was  soon  confined  to  bed  ;  limbs  became  strongl}'  flexed  ; 
screamed  a  good  deal,  but  showed  no  signs  of  intelligence. 
All  evacuations  were  passed  under  her ;  very  emaciated  ; 
bed-sores  developed.  No  convulsions  were  noted.  Died 
aged  i6.      (Abstract,  Wiglesworth,  loc.  cit.,  p.  359.) 

GENERAL     PARESIS     FOLLOWING     ACCUSATION    OF     THEFT. 
AN    ADOLESCENT    CASE. 

A  young  woman  of  18,  while  going  to  a  shop,  dropped 
some  money  and  a  man  saw  her  pick  it  up.  He  accused 
her  of  stealing  it  and  gave  her  in  charge.  When  taken 
before  the  magistrate,  she  was  unable  to  make  a  reply,  and 
was  sent  to  prison  for  fourteen  days.  On  returning  home, 
her  father  found  her  entirelv  altered  :  talked  of  her  wealth, 
etc.,  and  he  was  told  she  had  a  kind  of  fit  in  prison. 
(Abstract,  Sankey,  Mental  Diseases,  p.  292.) 

A    CASE    OF   JUVENILE    GENERAL    PARESIS    AT    THE 
AGE    OF    NINE    YEARS. 

Raymond  reports  the  case  of  a  girl,  ast.  9,  who  showed 
progressive  intellectual  weakness,  almost  complete  loss  of 
memory,  sensory  motor  disturbances,  localized  on  the  right 
side,  disorder  of  speech  and  trembling  of  the  lips,  inequality 
of  the  pupils,  with  abolition  of  the  pupillary  reflexes, 
n3'stagmiform  movements  and  slight  strabismus,  double, 
non-congenital,  pigmented  retinitis,  and  exaggeration  of 
the  reflexes.  The  psychic  symptoms  were  temporarily 
benefited  by  mixed  treatment.  The  disease  was  thought 
to  be  one  of  organic  cerebral  origin  and  general  paralysis 
was  diagnosed.  She  died  several  months  later  from  a 
tuberculous    broncho-pneumonia.      Her  brain  was  typical 


JUVENILE    GENERAL    PARESIS.  lOI 

of    general    paralysis.      (Abstract,    Philadelphia    Medical 
Journal,  Vol.  5,  p.  680.) 

A    CASE    OF    GENERAL    PARESIS    IN    A    GIRL    NINE    YEARS 
AND    THREE    QUARTERS    OLD. 

E.  E.  C,  female,  admitted  March,  1894.  It  was  the  first 
attack  and  of  five  months'  duration  ;  she  was  dangerous,  but 
neither  epileptic  nor  suicidal.  No  history  of  alcohol,  phthi- 
sis or  insanity.  Born  January,  1884.  Cause  of  insanity  said 
to  be  a  fall  which  she  had  in  April,  1893,  but  no  history  of 
her  head  being  injured  and  she  returned  to  school  in  a  few 
days.  October  14th  she  was  admitted,  stated  to  be  suffer- 
ing from  hydrocephalus  and  chorea  ;  she  had  been  "  rather 
strange"  but  previously  had  been  a  child  of  average  intelli- 
gence— able  to  read  and  write,  etc.  On  admission  to  hospital 
she  was  pale  and  thin,  looking  older  than  nine  years  ;  weak 
intellect,  with  slight  choreic  movements.  November  7, 
she  has  had  alternate  excitement  and  depression ;  pupils 
unequal,  and  general  nutrition  improved.  November  18, 
constantly  screaming.  Her  nightly  temperature  rose  on  a 
few  occasions  to  99°  and  once  to  100.4°.  After  leaving 
hospital  she  began  to  show  symptoms  of  insanity,  and  had 
sudden  fits  of  crying  ;  at  times,  restless  and  violent,  at  others 
silent  and  depressed  ;  she  did  not  recognize  her  parents ; 
thought  she  had  lost  her  money.  Her  speech  had  begun 
to  fail  when  admitted  to  asylum.  She  was  anemic,  pupils 
semi-dilated,  right  reacts  normally,  left  is  fixed ;  head  of 
large  size ;  tongue  straight,  slightly  furred ;  palate  not 
unduly  arched  ;  body  well  nourished  ;  heart  and  lungs  nor- 
mal ;  pulse  104,  knee-jerk  present,  no  clonus,  she  showed 
profound  dementia,  no  reply  to  questions.  "Mother,"  the 
only  word  she  says.  She  constantly  cries  without  appar- 
ent cause  ;  vicious,  bites  and  scratches  those  around  her, 
requires  feeding  and  is  unclean.  April  21,  menstruated; 
in  the  same  demented  state  :  grinds  her  teeth  ;  difficulty  in 
swallowing  ;  deteriorated  physically  until  September  18 
when  she  had  epileptiform  convulsions  chiefly  affecting 
right  side  and  followed  by  paresis,  which  passed  off  on 
September   23.       She  walked  with  an  inclination  of  her 


I02  VARIETIES    OF    GENERAL    PARESIS. 

body  to  the  right,  left  pupil  dilated,  right  contracted.  Oc- 
tober 26,  dilatation  of  left  pupil  and  flattening  of  left  side 
of  face ;  right  pupil  semi-dilated  and  reacts  sluggishh*, 
no  reaction  in  left.  December  10,  more  feeble,  grinds 
her  teeth,  is  sucking  and  picking  at  the  bed  clothes,  can 
swallow  only  a  little  food  at  once.  February  7,  she  is 
almost  moribund.  She  takes  no  notice  of  anything  ;  swal- 
lows with  great  difficulty  and  regurgitates  most  of  her 
food  ;  grinding  her  teeth  and  screaming  out ;  yery  dirty. 
Died  in  February,  1895.  (Abstract,  E.  L.  Dunn,  Journal 
of  Mental  Science,  \'ol.  41,  p.  482.) 

GENERAL    PARESIS    IN    TWO    SISTERS    AT    EARLY    LIFE. 

Ida,  was  healthy  as  a  baby  and  seemed  in  every  way 
normal ;  she  was  eyen  considered  yery  bright,  but  when 
aged  about  10  she  was  thought  to  be  growing  lazy  ;  instead 
of  playing  would  sit  about  the  house  in  an  apathetic  way. 
She  frequently  complained  of  stomach-ache,  but  had  no 
vomiting.  On  account  of  this  trouble  she  was  kept  out  of 
school.  When  aged  about  11  she  began  to  be  unsteady 
in  her  gait  and  had  to  be  guided  around.  "  Two  years 
we  dragged  her  around,  two  years  she  sat  in  a  chair  and 
two  years  she  was  in  bed."  When  aged  14  her  legs  had 
a  tendency  to  be  drawn  up,  and  later  this  became  so 
marked  that  even  passive  extension  was  difficult ;  a  similar 
condition  also  appeared  in  the  arms.  For  the  last  two 
years  she  could  not  sit  up  in  a  chair ;  her  voice  became 
coarser  and  speech  indistinct,  at  the  end  turning  into  a 
mumble.  The  mental  condition  approached  a  complete 
dementia  and  a  year  before  death  she  knew  no  one.  She 
lay  in  bed  contracted,  untidy,  mumbling,  picking  at  her 
bed  clothes  and  unable  to  help  herself  in  any  way.  There 
was  no  excitement  or  delusions,  and  no  convulsions  except 
a  series  of  them  shortly  before  death.  She  died  in  con- 
vulsions a  week  after  their  onset. 

Rosa,  now  19  years  old,  has  been  a  healthy  child  and 
of  average  intelligence  up  to  her  fifteenth  year,  and  has 
been  considered  feeble-minded  by  her  famil)'^  since  her 
sixteenth  year.     She  has  had  no  excitement,  delusions  or 


JUVENILE    GENERAL    PARESIS.  I03 

hallucinations.  She  first  showed  an  inability  to  follow 
school  work  ;  then  a  lack  of  interest  in,  and  an  inability  to 
understand,  things,  however  simple.  She  could  do  cro- 
chet work,  but  no  one  could  teach  her  a  stitch  different 
from  the  one  she  had  always  known.  For  two  or  three 
years  her  gait  has  been  changed  and  she  is  somewhat  un- 
certain ;  her  speech  gradually  became  altered.  She  has 
had  no  convulsions.  After  arriving  at  the  hospital,  she  was 
not  clear  where  she  was,  and  did  not  mind  her  sister's 
leaving  her.  Afterwards,  she  said  she  was  homesick,  but 
was  easily  made  to  forget  it.  She  was  quiet  and  orderly, 
and  absolutely  unable  to  appreciate  her  surroundings. 
When  asked  to,  she  described  a  picture  in  a  very  elemen- 
tary manner;  her  behavior  was  often  silly.  During  an 
examination  she  would  tell  a  perfectly  irrelevant  incident 
or  laugh  convulsively.  She  could  recite  poems  she  had 
learned  at  school,  but  did  not  grasp  their  meaning,  for  she 
often  left  out  lines  and  words  without  noticing  it.  When 
asked  to  read,  her  mistakes  were  characteristic.  Individ- 
ual letters  and  most  small  words  were  correctly  read  when 
shown  alone  ;  longer  words  could  not  be  read  even  after 
spelling,  or  they  were  mispronounced,  as  "laze"  for 
lizard,  "  colking  "  for  choking,  etc.  Figures  could  be  read, 
sometimes  four  together,  but  never  more.  Writing  showed 
mental  defects  analogous  to  those  expressed  in  reading 
and  also  tremulousness,  at  once  suggesting  general  pare- 
sis. She  could  not  multiply  correctly  with  numbers  larger 
than  four,  and  she  did  multiplication  better  than  addition 
or  division.  All  that  she  knew  depended  entirely  on  some 
well  rooted  association  ;  no  amount  of  practice  improved 
her.  (It  should  be  remembered  that  she  had  been  to  school 
up  to  her  fifteenth  year.)  The  gait  was  tottering,  the  legs 
held  far  apart  and  stiffly ;  walking  as  though  she  was  flat- 
footed  and  wavering  from  a  straight  line.  The  arms, 
during  walking,  were  held  away  from  the  body,  as  if  for 
balancing.  She  could  stand  with  eyes  closed  and  feet 
together,  but  not  at  all  on  one  foot.  Her  speech  was  indis- 
tinct, monotonous,  high-pitched  and  had  a  certain  vibra- 
tion to  it ;  some  words  are  slurred  over,   and  there  is  a 


I04  VARIETIES    OF    GENERAL    PARESIS. 

coarse  tremor  about  mouth  and  tongue  ;  the  face  is  some- 
what one-sided  ;  the  patellar  reflexes  have  been  exaggerated 
and  there  has  been  patellar  clonus  but  only  slight  ankle 
clonus.  The  reflexes  in  the  arms  were  increased;  the 
pupils  have  been  unequal  and  do  not  react  to  light  or  ac- 
commodation ;  she  perceives  tactile  impressions  well,  but 
pain  sensations  not  so  well ;  she  could  not  feel  the  prick 
of  a  pin  or  the  faradic  or  galvanic  current.  She  shows 
no  signs  of  hereditary  syphilis. 

These  two  girls  are  the  youngest  of  a  family  of  seven. 
The  others  are  healthy  and  normal,  and  show  no  signs  of 
hereditary  syphilis.  The  mother  had  no  miscarriages. 
The  father,  a  Dane,  has  been  unable  to  work  for  twelve 
years,  although  only  sixty-one.  He  often  became  dizzy 
and  could  not  direct  his  hands  properly.  Six  years  ago,  he 
suddenly  became  pale,  fell  down  and  was  weak  on  one  side. 
He  recovered  completely.  He  often  falls,  partly  because 
he  gets  dizzy,  partly  because  he  stumbles.  Last  year,  he 
had  two  "  boils  "  on  his  forehead  containing  dead  bone  ; 
he  has  been  irritable  for  years  ;  denies  syphilis  ;  he  had 
considerable  facial  tremor ;  speech  not  altered ;  tongue 
normal ;  handwriting  tremulous ;  muscle  power  fair  and 
equal  on  the  two  sides  ;  gait  tottering  but  not  ataxic ;  he 
stood  well  with  his  eyes  closed  ;  knee-jerks  are  diminished  ; 
pupils  normal ;   arteries  are  thickened. 

Evidently  it  is  not  general  paresis.  (Abstract,  Hoch, 
Aug.,  Journal  of  Nervous  &  Mental  Diseases,  Vol.  24, 
p.  68.) 

A    CASE    OF    PRECOCIOUS    GENERAL    PARESIS. 

A  boy  of  neuropathic  heredity,  both  paternal  grand- 
parents having  had  paralytic  troubles,  a  cousin  having 
been  insane  and  his  father  formerly  intemperate.  No 
evidence  of  syphilis.  During  childhood  was  healthy,  and 
a  good  scholar.  At  age  of  14  he  was  put  to  work.  After  a 
month,  his  intelligence  began  to  fail,  had  to  be  told  every- 
thing that  he  had  to  do,  wrote  badly,  could  not  make 
arithmetical  calculations,  seemed  changed,  taciturn  and 
silly,  stammered  at  times,  hands  trembled  when  tired.  On 
admission,  he  had  wet  his  bed  for  two  months ;  backward 


JUVENILE    GENERAL    PARESIS.  I05 

in  physical  development ;  slight  evidences  of  puberty,  al- 
though 17.  Expression  dull,  walk  clumsy,  all  movements 
awkward.  His  mind  much  enfeebled,  seemed  apathetic 
and  indifferent.  Memory  poor,  no  delusions  ;  tremor  of 
tongue  and  lips  extending  at  times  to  other  facial  muscles ; 
articulation  imperfect,  especially  when  tired  and  with  the 
lingual  consonants  ;  tremulous  hands,  clumsiness  of  hand- 
writing with  a  tendency  to  omit  and  misplace  ;  inequality 
of  pupils  ;  attacks  of  formication,  beginning  in  right  foot 
and  involving  the  whole  right  side  ;  headache,  general 
muscular  weakness,  no  localized  paralysis,  knee-jerk  ex- 
aggerated. (Abstract,  Charcot,  Arch,  de  Neurol.,  March, 
1892.) 

A    CASE    OF    DEVELOPMENTAL    GENERAL    PARESIS. 

Annie  H.,  admitted  to  Morningside,  is  the  youngest  of 
a  family  of  four.  The  second  eldest  was  a  miscarriage  ; 
the  other  two  are  healthy.  The  patient  was  a  normal 
child  up  to  the  age  of  eight.  She  got  on  well  at  school, 
until  she  was  eight  when  a  bad  stammer  developed.  She 
then  did  work  around  the  house,  but  the  stammer  got  worse. 
When  aged  sixteen  she  was  noticed  to  be  more  stupid 
than  usual  and  forgot  things  ;  did  not  do  her  work  well. 
These  changes  gradually  increased ;  four  years  ago  she 
was  sent  to  poor-house,  until  she  came  to  asylum.  She  had 
required  constant  attention,  had  no  attacks  of  excitement, 
no  delusions,  spoke  less  and  less  and  stammer  got  worse. 
On  admission,  aged  twenty-three,  she  was  well  developed  ; 
absence  of  expression  in  face  and  eyes  ;  movements  leth- 
argic ;  there  was  difficulty  in  rousing  her  attention  to 
questions,  would  smile  in  a  meaningless  way,  without 
provocation.  Emotionally  she  was  happy  rather  than 
depressed.  There  was  considerable  muscular  weakness, 
some  incoordination  and  slight  tremors  of  upper  lip ;  knee- 
jerk  and  other  reflexes  exaggerated ;  pupils  unequal, 
slightly  irregular,  and  did  not  react  to  accommodation  ;  she 
had  menstruated  only  once  or  twice  when  aged  sixteen ; 
teeth  not  well  shaped ;  thickening  of  tibial  bones,  presum- 
ably of  a  syphilitic  character.  Since  admission,  she  has  lost 
9 


lo6  VARIETIES   OF   GENERAL   PARESIS. 

flesh  and  strength,  confined  to  bed,  very  helpless  ;  all  the 
symptoms  are  now  more  pronounced.  There  have  been 
slight  rises  in  temperature  with  increased  mental  obscura- 
tion, never,  however,  reaching  unconsciousness,  regarded 
as  congestive  attacks.  During  them  there  is  headache  but 
no  convulsive  movements.  She  will  not  live  many  months 
more.  ( Abstract,  Middlemass,  Journal  of  Mental  Sci- 
ence, Vol.  40,  p.  41.) 

General  Paresis  in  Woman. —  The  disease  runs  a 
milder  and  longer  average  course  among  women, 
and  remissions  are  less  frequent.  It  occurs  earlier 
in  women  and  the  fraction  of  female  paretics  under 
the  age  of  thirt}'  is  nearly  three  times  that  of  male 
paretics  (Mickle).  Recent  statistics  give  the  pro- 
portion of  male  and  female  cases  as  seven  to  one. 
Hereditary  predisposition  is  frequent,  and  in  fully 
one  third  of  the  cases  syphilis  is  the  etiological  fac- 
tor, some  writers  placing  it  much  higher.  Spinal 
symptoms  are  less  noticeable  than  in  the  opposite 
sex,  and  the  ascending  form  is  rare. 

Alteration  of  the  menses,  apart  from  that  due  to 
age,  has  been  frequently  noticed,  but  the  influence  of 
the  climacteric,  formerly  so  emphasized,  does  not  ap- 
pear to  have  the  importance  attributed  to  it.  The 
course  of  the  disease  does  not  differ,  as  a  rule,  from 
that  generally  described,  euphoria  being  present  in 
most  cases,  while  excitement  and  expansive  delu- 
sions, though  not  infrequent,  do  not  reach  the  height 
common  in  men.  Although  paresis  is  so  common 
among  men  of  the  higher  classes,  women  of  these 
classes,  as  stated  elsewhere,  are  not  frequently  at- 
tacked; but  when  women  drink  much  bad  liquor  and 
live  excited,  irregular  lives,  they  are  readily  subject 
to  the  disease. 

Some  writers  speak  of  a  form  of  the  disease  ob- 
served in  late  years,  aflfecting  man  and  wife  at  the 


PUte  VII. 


GENERAL  PARESIS  IN  WOMEN. 


GENERAL   PARESIS   IN  WOMAN.  I07 

same  time  and  which  is  called  "  conjugal  general 
paresis."  It  has  its  explanation  in  a  reciprocal  S3'ph- 
ilization. 

A    CASE    OF    CONJUGAL    GENERAL    PARESIS. 

A  woman  admitted  at  the  same  time  with  her  husband, 
both  fairly  intelligent,  and  with  a  seeming  neurasthenic 
confusional  state  ;  wife  had  no  motor  symptoms  ;  husband, 
diagnosed  as  general  paretic  ;  he  rapidly  went  into  an  active 
maniacal  state,  delirious,  persistent  diarrhoea,  died  of  ex- 
haustion in  three  months,  a  few  hours  after  a  convulsion  ; 
died  before  being  extremely  paretic.  The  woman,  although 
feeble-minded,  went  home,  returned  in  a  year,  and  later 
showed  dementia,  then  motor  signs,  slight  cerebral  attacks, 
steady  decline  and  death.  (Abstract,  Phelps,  American 
Journal  of  Insanity,  Vol.  53,  p.  59.) 

GENERAL    PARESIS    IN    A    WOMAN. 

Mary  A.,  married,  aet.  36.  Formerly  an  actress;  no 
insane  relatives  ;  present  attack  the  first ;  supposed  cause, 
great  anxiety  and  money  troubles  of  her  husband.  First 
symptoms  appeared  nine  months  before  admission.  She 
became  excited  and  incoherent  for  twenty-four  hours  and 
thereafter  showed  mental  weakness.  On  admission,  she  had 
vacant  expression,  wanted  to  be  dressed  elaborately,  think- 
ing herself  a  great  person.  When  spoken  to  she  replied 
by  saying  "  jollv."  She  walked  awkwardly;  speech 
hesitating ;  comprehension  dull ;  appetite  good ;  loss  of 
power  ov,er  bladder  and  rectum.  Within  one  month  of 
admission  she  became  nois}'',  violent,  destructive  and  re- 
fused to  take  food.  An  erythematous  rash,  followed  by 
large  bullae,  appeared  on  legs  ;  she  had  subnormal  tem- 
perature. She  steadily  lost  strength  and  died.  (Abstract, 
Savage,  of.  ci't.,  p.  302.) 

A    CASE    OF    GENERAL    PARESIS    IN    THE    PRODROMAL 
STAGE    IN    WOMAN. 

Mrs. — ,  aet.  49  years.  Four  years  ago  consulted  oculist 
for  asthenopia,  and  especially  for  difficulty  in  accommo- 
dation.      No  mental  symptoms  were  observed,   although 


Io8  VARIETIES    OF    GENERAL    PARESIS. 

at  that  time  they  were  not  carefully  looked  for.  One 
year  afterward,  mental  symptoms,  considered  of  no  im- 
port, were  observed,  she  being  exhausted  by  the  care  of 
an  ill  mother  and  sister.  One  year  later  still,  she  began 
to  have  attacks  of  loss  of  consciousness,  similar  to  petit 
mal,  after  lying  down  or  sleeping.  She  had  several  while 
standing,  and  thought  she  would  have  fallen  but  for  sup- 
port. She  remembered  much  less  well  than  formerly  ;  was 
irritable,  apathetic,  indifferent,  disinclined  to  exertion.  She 
could  not  understand  or  remember  clearly  what  was  read 
to  her,  although  she  could  talk  of  it  in  a  general  way. 
Her  husband  was  surprised  at  some  of  her  incorrect  state- 
ments to  the  physician.  He  had  noticed  that  she  forgot 
where  she  put  things,  and  what  she  was  going  to  do. 
Showed  less  life  and  ambition  in  her  face  ;  loss  of  physical 
strength,  especially  in  her  legs,  noticed  when  going  up 
and  down  stairs.  After  walking  a  half  mile  she  became 
tired,  and  her  gait  became  unsteady  and  tottering.  She 
was  dizzy  at  times,  rarely  had  headache  ;  could  not  fix  her 
eyes  to  read.  Hands  tremulous ;  slight  hesitation  in 
speech,  which  her  husband  and  she  thought  natural ;  and 
articulation  deliberate,  almost  sluggish.  In  spite  of  good 
appetite  and  hearty  eating  she  lost  sixteen  pounds.  I  have 
not  watched  this  case  to  termination  but  have  no  doubt  of 
the  result.     (Abstract,  Folsom,  loc.  cit.^  p.  17.) 

GENERAL    PARESIS    IN    A    YOUNG    W^OMAN. 

Martha  C,  admitted,  aged  20,  the  youngest  of  eight 
children.  The  second  and  third  were  still-born  at  the 
seventh  month  ;  the  fourth  had  deformity  of  the  spine,  and 
died  five  months  after ;  the  fifth  was  a  seven-month  child 
and  lived  only  two  days ;  the  others  were  living  and 
healthy  except  patient.  Five  years  ago  patient's  develop- 
ment came  to  a  standstill,  finally  retrogression  occurred, 
without  any  violent  physical  or  mental  course.  First, 
alteration  in  speech,  which  became  thick  and  slow  ;  she  also 
became  stupid.  All  these  symptoms  grew  more  pro- 
nounced, she  remained  at  home,  had  no  fits  or  congestive 
attacks,  no  excitement  or  delusions.     Weakness  of  mind 


GENERAL    PARESIS    IN    WOMAN.  I09 

and  bod}",  onh',  led  to  her  admission  :  ph3'sicallv  she  was 
fairly  well  developed ;  blank  expression  of  face  ;  often 
nervous  or  frightened  ;  she  would  laugh  or  cr}"  on  slight 
provocation  ;  memor}^  much  impaired  ;  no  grandiose  delu- 
sions ;  gait  unstead}^,  tongue  and  lips  tremulous,  speech 
slurred ;  pupils  slightly  dilated,  the  left  larger  than  right, 
both  irregular  and  reacting  slowly  to  light,  occasional 
nystagmus ;  knee-jerk  exaggerated ;  had  not  menstru- 
ated;  chest  rachitic,  teeth  syphilitic:  angles  of  mouth 
puckered  as  if  from  old  ulceration.  She  became  weaker 
in  body,  muscular  tremulousness  and  incoordination  in- 
creased, had  to  be  kept  in  bed.  Mental  dissolution  also 
advanced  steadily,  resulting  in  almost  complete  dementia. 
There  was  no  outstanding  event  during  the  illness.  Died 
less  than  six  months  after  admission,  the  disease  having 
taken  five  and  a  half  years  to  run  its  course.  (Abstract, 
Middlemass,  loc.  cit.,  p.  38.) 

A    CASE    OF    GENERAL    PARESIS    IN    THE    PRODROMAL    STAGE 
IN    WOMAN    TREATED    FOR    MALARIA. 

A  strong,  health}^  lady ;  forced  to  support  herself  be- 
cause her  husband  had  died  four  years  before  of  epilepsy. 
She  became  an  attendant  in  a  public  institution ;  after  two 
years  had  to  give  it  up,  due  to  diminishing  physical 
strength  and  mental  indisposition  or  irritability.  Went  to 
New  York  city  and  was  there  treated  for  malaria.  She 
complained  of  a  feeling  of  weariness  and  lameness  after 
walking.  Her  conversation  did  not  indicate  mental  dis- 
ease, but  investigation  showed  that  attention,  concentra- 
tion, memory  and  readiness  of  perception  were  impaired. 
There  was  deliberateness  of  speech  and  slowness  of 
physical  and  mental  action.  She  died  four  years  after- 
wards in  an  asylum,  a  paretic.  (x\bstract,  Folsom,  loc. 
cit.,  p.  8.) 

Senile  General  Paresis. — See  section  on  age  under 
etiology. 


CHAPTER   IX. 

PARTICULAR    SYMPTOMATOLOGY. 

Moral  Perversion. — One  of  the  most  definite  of  the 
prodromal  symptoms  and  sometimes  the  one  first 
noted,  is  that  of  moral  perversion.  It  is  a  result  of 
mental  disintegration,  and  may  occur  years  before  a 
marked  outbreak  of  the  disease.  In  other  cases 
"  simultaneously  with  memor}^,  will  and  emotional 
unbalance  the  morals  begin  to  totter."  Here  the 
symptoms  are  so  obvious  that  a  short  time  suffices  to 
convince  the  most  incredulous  that  disease  is  at  work. 
The  patient  forgets  business  engagements,  social 
proprieties, and  moral  obligations,  and  he  is  entirely  ob- 
livious of  responsibility  in  any  one  of  them.  Positive 
misdoing  rapidly  develops  ;  he  uses  improper  language, 
mistreats  wife  and  family,  and  indulges  in  excesses 
of  all  sorts.  All  of  these  tend  to  hasten  the  disease. 
At  necessary  remonstrance  he  creates  a  disturbance, 
perhaps  uses  violence,  and  is  soon  adjudged  insane. 

But  in  a  majority  of  cases  the  onset  is  much  more 
gradual ;  little  by  little  the  character  and  language 
change.  The  moral  lapse  seems  at  first  a  fault  of 
memory,  a  thoughtless  appropriation  of  trifling  arti- 
cles, that  naturally  he  would  not  desire,  and,  perhaps, 
a  seemingly  unconscious  error  of  propriety.  But  a 
little  later  he  steals  in  the  most  open  way — anything 
and  perhaps  gives  it  away  at  once. 

These  persons  are  most  unconcerned  when  caught 
thieving  and  at  once  give  a  reason  for  their  conduct. 
Often  the  aflTections  change,  and  the  sense  of  moral 
responsibility  is  wholly  lost.  This  is  always  con- 
no 


MORAL  PERVERSION.  Ill 

nected  with  the  progressive  advance  of  the  mental 
weakness.  It  has  been  pointed  out  that  these  moral 
lapses  differ  materially  from  the  overt  acts  of  those 
afflicted  with  so-called  moral  insanity.  In  the 
latter,  as  the  result  of  a  perverted  moral  sense  and 
defective  inhibitory  action  the  instinctive  impulses 
gain  ascendency.  On  the  other  hand  it  is  shown  that 
in  the  paretic  the  deficient  moral  tone  is  due  to  a 
clouded  intellect,  the  result  of  incipient  dementia. 
This  is  quite  apparent  if  we  analyze  the  act,  not  only 
in  respect  to  its  motive,  which  is  not  impulsive  but 
casual,  but  also  in  the  mode  of  its  accomplishment, 
which  is  devoid  of  forethought  and  judgment. 

AN    ACT    OF    ARSON    IN    A    PARETIC. 

S.  B.,  set.  40,  laborer,  single,  tried  for  burning  a  stack 
of  straw.  Fourteen  years  before  he  had  severe  head  in- 
jury from  a  piece  of  falling  coal.  (Abstract,  Baker,  J. 
Journal  of  Mental  Science,  Vol.  35,  p.  50.) 

INDECENT    EXPOSURE    IN    A    PARETIC. 

A  professional  man,  who  was  arrested  for  indecent  ex- 
posure and  fined  by  the  court,  retired  from  the  court  room 
and  repeated  the  offense.  (Abstract,  Stearns,  Mental  Dis- 
eases, p.  478.) 

A    STUPID    THEFT    BY    A    PARETIC. 

A  patient  under  my  care  broke  into  a  shop  window,  ab- 
stracted a  handful  of  cigars,  and  then  sat  down  on  the  curb- 
stone to  enjoy  them,  when  he  had  sufficient  money  about 
him  to  supply  his  needs.  (Abstract,  Berkley,  Mental  Dis- 
eases, p.   174.) 

REPEATED    PILFERING  ;    MARRIED    A    MULATTO. 

A  patient,  at  an  early  period  in  his  disease,  would  pick 
up  small  articles  from  store  counters  and  put  them  in  his 
pockets,  and  would  not  miss  them  when  others  removed 


112  PARTICULAR     SYMPTOMATOLOGY. 

them.  He  always  strongly  affirmed  that  he  had  bought 
articles,  or  that  they  had  been  given  to  him  years  before. 
This  patient,  a  physician,  had  married  a  mulatto  woman 
two  or  three  years  before  his  friends  had  him  placed  under 
legal  restraint.     (Abstract,  Stearns,  of.  cit.,  p.  472.) 

DISHONEST    TRANSACTION    OF    A    RAILROAD    OFFICIAL 
WHO    PROVED    TO    BE    A    PARETIC. 

A  railroad  official,  well  known  for  his  thrift  and  busi- 
ness ability,  with  no  previous  mental  symptoms,  went  to  a 
small  town  in  western  Virginia,  where  he  was  known. 
He  took  a  room  at  the  principal  hotel,  purchased  several 
properties,  and  told  his  friends  that  a  railroad  was  to  run 
through  the  place,  and  that  he  had  bought  the  properties 
so  as  to  forestall  the  projectors  of  the  road,  as  they  wished 
to  locate  their  depots  and  offices  on  these  sites.  He  was  so 
well  known  for  his  business  acumen  that  a  syndicate  was 
formed  by  the  local  people,  and  the  land  rebought  at  an 
advance  of  thirty  thousand  dollars.  The  man  left  the 
town  with  his  gains,  which  he  dissipated  within  a  few  days. 
(Abstract,  Berkley,  op.  cit.,  p.  173.) 

THIEVING    BY    PATIENT    EIGHT    YEARS     BEFORE    ONSET    OF 

DISEASE. 

An  old  government  officer,  for  eight  years  prior  to 
his  reception  in  an  asylum,  had  been  guilty  of  repeated 
abstractions  of  articles  at  public  sales  which  he  attended 
officially.  After  the  last  theft  he  was  arrested.  His  phy- 
sician at  once  saw  that  he  was  mentally  affected  ;  pronun- 
ciation embarrassed,  face  "petrified,"  walk  heavy;  when 
asked  as  to  the  circumstances  of  his  arrest,  the  patient 
answered  without  remorse  or  shame:  "The  people  who 
put  me  in  prison  are  imbeciles,  who  know  nothing  of  our 
professional  usages.  There  is  a  custom  among  us,  known 
as  the  '  cote  G,'  to  choose  some  object  of  slight  value  and 
retain  it  when  taking  the  inventory."  And  with  this  he 
took  from  his  pockets  a  meerschaum  pipe  and  a  gold- 
mounted  tobacco  pouch.      He  was  pronounced  a  paretic. 


SEXUAL    INSTINCT.  II3 

and  died  a  few  months  later.     (Bierre  de  Boismont,  vide 
Spitzka  on  Insanity,  p.  187.) 

A    PARETIC    FISHERMAN    ARRESTED    FOR    THEFT. 

A  fisherman,  who  had  presented  signs  of  paretic  de- 
mentia for  six  months,  as  it  was  subsequently  ascertained, 
was  detected  emptying  the  nets  of  others  and  appropriat- 
ing their  contents.  He  was  first  beaten  by  the  owners  and 
then  taken  before  the  court.  Here  he  declared  that  his 
oars  had  become  entangled  in  the  nets  and  that  he  had 
taken  the  fish  out  in  order  to  rearrange  the  nets,  intending 
to  replace  the  former.  This  explanation  was  rejected  as 
a  "  cunning  evasion,"  and  a  physician  pronounced  him  of 
sound  mind,  although  suspicions  that  he  was  insane  were 
suggested  by  witnesses.  The  prisoner  also  announced  the 
project  of  running  a  net  across  the  Elbe  river  to  be  dragged 
by  two  steamers,  thus  catching  all  the  fish  at  one  swoop. 
(Simon,  x'/tfig  Spitzka  on  Insanity,  p.  188.) 

Sexual  Instinct. — In  general  paresis  there  is  an 
insane  exaltation  of  the  sexual  nature  in  many  cases. 
The  sexual  power  may  be  weak  but  the  passion  very 
strong.  The  female  betrays  much  personal  vanity 
and  self-consciousness  in  the  presence  of  men;  she 
is  often  engaged  in  matrimonial  designs.  Frequently, 
the  male  patient  suffers  from  the  delusion  that  his 
wife  is  unfaithful  to  him,  while  he  may  run  into  vile 
excesses  himself. 

LOSS    OF     SEXUAL    ABILITY    IN     PARESIS. 

Loss  of  sexual  ability  in  one  case  was  among  the  ear- 
liest indications  of  the  disease.  (Abstract,  Stearns,  Men- 
tal Diseases,  p.  472.) 

LOSS    OF    SEXUAL    ABILITY    AS    AN    EARLY    SYMPTOM. 

In  a  case  of  the  writer's  experience,  the  wife  mentioned 
loss  of  sexual  power  as  an  early  symptom  in  the  husband, 
although  the  desire  was  stronger  than  normal. 


114  PARTICULAR     SYMPTOMATOLOGY. 

PERVERSION    OF    SEXUAL    INSTINCT    IN    PARESIS. 

Another  case,  which  was  in  the  second  stage,  displayed 
little  or  no  natural  sexual  desire,  but  at  the  same  time, 
shamelessly  masturbated  in  the  presence  of  his  wife,  to 
whom  he  was  devotedly  attached. 

Hallucinations. — Hallucinations  of  the  special  senses 
occur  in  about  half  the  cases  of  general  paresis. 
Visual  and  auditory  hallucinations  are  the  most  com- 
mon and  according  to  Mickle  are  found  in  forty  per 
cent,  of  the  cases;  next  in  order,  are  tactile,  gustatory 
and  olfactory  hallucinations,  which  are  present  in 
about  twelve  per  cent.  Hallucination  of  all  of  the 
special  senses  is  sometimes  found  in  the  advanced 
stages,  the  patient  showing  visual,  auditory,  olfactory, 
gustatory  and  tactile  perversion,  the  result  of  the  ad- 
vancing degeneration  of  the  neurons  of  the  cortex. 

The  hallucinations  of  paretics  are  usually  variable, 
unstable  and  inconsistent,  being  less  systematized  than 
those  of  many  other  forms  of  insanity.  Spitzka  com- 
pares them  with  those  found  in  some  of  the  acute  in- 
sanities, such  as  in  alcoholic  insanity  and  contrasts 
them  with  those  of  paranoia,  where  they  are  fixed 
and  systematized.  Hallucinations,  illusions  and  de- 
lusions are  liable  to  be  combined  in  varying  degree, 
and  it  is  troublesome,  if  not  occasionally  impossible 
in  practice,  to  separate  the  long  catalogue  of  these 
perversions  into  their  respective  category.  Again, 
prominent  delusions  may  mask  the  less  conspicuous 
manifestations  of  the  other  morbid  perversions,  and 
to  this  fact  may  be  attributed  the  paucity  of  hallu- 
cinations among  paretics  that  is  found  in  the  experi- 
ence of  some  observers. 

Visceral  sense-impressions,  scarcely  noticed  in 
normal  conditions,  are  vivid  in  the  paretic  and  be- 
come linked  with  his   delusions.     Especially  is  this 


HALLUCINATIONS.  II5 

the  case  in  the  hypochondriacal  form  when,  visceral 
sense-impressions  (illusions)  are  a  marked  feature  of 
the  perversion.  Joyful  hallucinations  accompany  the 
ambitious  deliria,  while  painful  ones  pursue  those 
afflicted  with  melancholic  depression.  In  one  case, 
countless  frogs  were  seen  by  the  patient  hopping 
about  him,  whose  intestines  bulging  out  from  the 
vent,  had  been  stuifed  into  their  mouths;  another 
patient  heard  voices  commanding  him  to  kill  some 
one,  in  order  that  he  might  himself  be  compelled  to 
commit  suicide  (Spitzka). 

Some  writers  hold  that  the  sense  of  pain,  expressed 
in  groans  and  cries  in  the  last  stage  of  the  malady,  is 
not  hallucinatory,  but  is  due  to  nervous  lesions,  either 
central  or  peripheral,  and  that  the  assurance  in  per- 
sonal strength,  frequently  so  confidently  expressed  in 
the  first  and  second  stages,  is  not  a  delusion,  but  more 
properly  an  hallucination,  due  to  the  morbid  perver- 
sion of  the  kinesthetic  sense. 

The  question  is  sometimes  asked  whether  hallu- 
cinations are  met  with  more  frequently  in  the  expan- 
sive, or  in  the  depressive  form  of  the  disease.  It 
seems  to  be  a  very  general  experience  that  they  are 
oftener  found  in  the  latter  cases,  or  it  may  be,  owing 
to  the  distressing  nature  of  these  hallucinations  that 
they  are  forced  more  readily  on  the  attention.  Camp- 
bell Clark  gives  a  striking  example  of  the  uncanny 
nature  of  these  hallucinations  in  the  depressant  form. 
The  patient  declared  that  he  had  seen  in  the  night  his 
house  filled  with  black  dogs,  and  the  noise  of  their 
howling  kept  him  awake  all  night.  He  had  the 
hallucination,  also,  that  a  drowned  man  was  touching 
him;  said  that  his  saliva  tasted  very  bitter  and  that  it 
was  poisoned;  that  laudanum  had  been  given  him; 
and  the  doctor  had  opened  him  in  his  sleep;  and  that 
he  had  been  blistered  with  two  fly  blisters. 


CHAPTER   X. 

PARTICULAR     SYMPTOMATOLOGY    i^C07ltinued^, 

Facial  Expression. — The  face  of  the  paretic  presents 
a  characteristic  lack  of  expression.  The  tense  facial 
muscles,  which  give  expression  to  the  individual  face 
by  the  special  lines  and  wrinkles  which  the}-  cause,  be- 
come enervated,  and  no  longer  respond  to  the  quick 
play  of  feeling,  which  may,  or  may  not,  still  exist  in 
the  mind.  In  either  case  the  expression  is  compara- 
tively characterless.  The  face  takes  on  a  putfy,  apa- 
thetic appearance,  somewhat  resembling  the  cast  of 
the  drunkard,  with  which  it  has  been  compared.  This 
expressionless,  mask-like  look  has  been  termed  "  the 
petrified  face." 

While  the  patient  is  uninterested  or  the  features 
are  in  repose,  the  expression  is  peculiarly  blank  and 
stolid,  but  when  animated  there  is  a  complexity  of 
expression  difficult  to  describe.  There  comes  a  tardy 
and  usually  but  a  partial  response  to  the  facial  mus- 
cles; the  face  may  beam  with  excitement,  the  eyes 
staring  and  the  mouth  smiling,  and  at  the  same  time 
the  lips  and  facial  muscles  become  tremulous,  so  that 
the  expression  is  a  mingled  one  of  pleasure,  pain 
and  surprise,  which  only  interest  or  excitement 
prompts. 

Frequently,  because  of  the  irregularities  of  inner- 
vation, one  part  of  the  face  expresses  one  emotion, 
while  another  part  expresses  a  different  one,  and,  as 
has  been  said,  it  "  reminds  one  of  a  badly  executed 
portrait,  in  which  the  features  do  not  harmonize  in 
their  expression"  (Sankey). 

ii6 


SPEECH.  117 

Some  parts  of  the  face  are  more  continually  in 
action  than  other  parts  and  they  show  first  the  lack 
of  control.  The  mouth  loses  its  firmness,  and  the 
lower  part  of  the  face  becomes  smooth  and  heavy; 
the  naso-labial  lines  disappear,  leaving  a  puff}-  and 
sometimes  pouting  look  about  the  mouth,  and  almost 
always  there  is  added  a  tremulousness  of  the  lips. 

Sometimes  there  is  a  sleepy  look  about  the  eyes, 
and  a  relaxing,  which  may  amount  to  a  paresis,  of 
the  muscles  of  the  upper  part  of  the  face,  causing  a 
drooping  of  the  eyebrows.  The  eyelids  sink,  and  a 
vacant  expression  is  the  result.  But,  again,  there 
may  be  a  muscular  twitching  about  the  eyebrows, 
and  a  muscular  tension  about  the  forehead,  which 
tends  to  keep  the  eyes  very  wide  open  and  to  pro- 
duce an  unusual  expression  of  unfelt  astonishment. 
Often  the  forehead  is  corrugated  and  remains  so  to 
the  end.  Towards  the  last  the  facial  aspect  is  dull, 
glassy  and  vacant,  giving  no  sign  of  emotion,  except- 
ing, now  and  then,  a  furtive  glance  of  amazement,  or 
of  fright. 

Speech. — The  speech  early  betrays  the  existence  of 
general  paresis.  This,  the  highest  expression  of  men- 
tal life,  the  most  delicate  of  motor-coordinations  in  the 
well-modulated  voice  and  clearly-enunciated  words, 
the  last  accomplishment  to  be  acquired,  is  the  first 
to  fail. 

The  complications  necessary  to  a  communica- 
tion of  ideas  must  necessarily  be  touched  on  every 
side  by  the  beginning  of  this  disease.  The  formerly 
clear  mind  is  troubled  by  a  sense  of  confusion,  an  in- 
ability to  command  immediate  control  of  the  mental 
processes ;  this  is  followed  by  intellectual  weakness  and 
by  impairment  of  memory  and  of  attention.  At  the 
same  time  a  slight  hesitancy  in  speech,  together  with 
a  trembling  or  slight  stiffening  of  the  upper  lip,  early 


I  1 8  PARTICULAR     SYMPTOMATOLOGY. 

shows  a  disordered  relation  between  ideation  and  the 

coordination  of  the  vocal  organs.  The  peculiarity  of 
speech  is  difficult  to  describe,  for  there  are  always 
slight  individual  differences,  but  it  is  so  characteristic 
that  heard  a  few  times  it  is  readily  recognized. 

Under  the  three  stages  of  the  established  disease 
will  be  found  a  detailed  description  of  the  paretic 
speech.  It  is  not  unusual  to  find  aphasia  associated 
with  paresis,  as  the  following  cases  illustrate: 

THREE   CASES    OF    GENERAL    PARESIS   EXHIBITING  APHASIA. 

1.  A  paretic,  when  received,  was  unable  to  express  him- 
self intelligently  ;  he  understood  what  was  said  to  him,  and 
could  repeat  words  spoken  to  him  without  difficulty. 
Motion  on  right  side  was  more  impaired  than  on  left. 
Subsequently,  an  epileptiform  attack  left  total  right  hemi- 
plegia and  complete  aphasia  continuing  until  death,  nine 
months  later. 

2.  A  paretic,  had  aphasia  on  admission,  being  complete 
word  deafness,  which  came  on  after  an  apoplectic  attack  ;  a 
vear  previously,  there  had  been  transient  right  hemiplegia, 
after  which  he  only  uttered  a  few  unintelligible  sounds ; 
he  understood  nothing  of  what  was  said  to  him  and  ex- 
pressed himself  by  gestures.     Death  from  edema  of  lungs. 

3.  The  patient's  illness  was  attributed  to  a  severe  blow 
on  the  head,  followed  later  by  an  apoplectic  seizure,  leav- 
ing right  hemiplegia  and  aphasia.  When  received  under 
treatment,  there  was  paralysis  with  contracture  of  the  right 
extremities,  general  muscular  weakness,  and  apparent 
inability  to  understand  what  was  said  ;  he  died  from  pneu- 
monia. (Abstract,  Rosenthal,  American  Journal  of  In- 
sanity, Vol.  46,  p.  398.) 

APHASIA    AS    AN    EARLY    PRODROMAL    SYMPTOM. 

The  wife  of  patient  noticed  temporary  loss  of  speech, 
followed  by  hesitation  and  tremor  nearly  eight  years 
before  serious  disease  was  suspected.  The  attacks  of 
aphasia  recurred  at  intervals  and  when  it  became  necessary 


Plate  VIII. 


Round  the  rugged  rocks  the  ragged  rascal  ran. 


Specimens  of  the  Handwriting  in  General  Paresis. 

These  are  facsimiles  of  the  handwriting  of  three  paretics,  all  of  whom  were  in  an 
advanced  stage  of  the  disease.  In  the  last  case  the  patient  was  found  to  be  too  much 
demented  to  complete  the  alliterative  lines,  so  he  was  then  given  the  easier  task  of 
writing  the  shorter  sentence.  Observe  in  the  first  instance  that  he  started  to  sign  his 
name  when  he  had  finished  the  first  word  of  the  sentence  ;  he  was  persuaded,  how- 
ever, to  continue  with  the  copy,  with  what  ill  success  may  be  seen,  after  the  abortive 
attempt  to  write  Edward,  his  christian  name. 


HANDWRITING.  II 9 

to  send  the  patient  to  an  asylum,  the  difficuhy  of  speech 
and  tremor  of  tongue  and  lips  were  well  marked.  (Abstract, 
Savage,  of.  cit.,  p.  286.) 

Handwriting. — The  handwriting  of  paretics  is  of 
importance,  as  it  early  shows  tremor  fin  the  wavy 
up-  or  down-strokes.  This  tremor  of  itself  will  not 
decide  the  case,  for  tremor  may  occur  with  age,  alco- 
holism or  in  diiferent  nervous  defects,  and  specimens 
of  handwriting  from  all  are  similar;  but  the  general 
paretic  shows  an  inability  to  control  the  attention  for 
any  length  of  time,  and  with  the  effort  comes  an  in- 
creasing weakness  of  understanding  and  memory. 

In  the  first  stages  the  patient  may  write  a  fairly 
steady  hand,  but  there  is  a  lack  of  carefulness  in  the 
finer  movements;  final  letters  are  often  omitted; 
lapses  of  words,  reduction  of  double  consonants,  rep- 
etitions of  words  or  even  of  sentences,  reduplication 
of  letters  or  syllables  all  tell  the  story  of  unusual 
effort  required  to  write  clearly.  Early  in  the  disease 
the  patient  may  notice  his  failure  to  write  rapidly  and 
by  writing  slowly  may  cause  a  decided  improvement, 
but  as  the  disease  advances  he  loses  this  power  of 
control.  The  handwriting  degenerates  to  a  scrawl, 
and  the  deviations  from  straight  lines  become  more 
apparent.  In  lengthy  documents  the  beginning  may 
be  fair,  but  as  the  patient  tires  a  little,  the  formation 
of  words  grows  more  irregular.  It  becomes  impos- 
sible for  him  to  follow  the  line;  he  writes  above  or 
below  it  but  usually  runs  obliquely  down  across  the 
page.  The  omission  of  words  happens  more  fre- 
quently, and  a  meaningless  repetition  of  even  whole 
sentences  may  occur. 

The  serious  mental  condition  is  apparent  in  these 
efforts,  as  well  as  the  lack  of  muscle  control;  the 
ideas  are  confused  and  the   sentence  seems  to  fade 


I20  PARTICULAR     SYMPTOMATOLOGY. 

from  the  mind  before  the  patient  can  put  it  on  the 
paper.  Many  patients  show  an  inclination  to  deal 
with  financial  affairs,  and  their  scrawling  letters  con- 
tain orders  for  expensive  jewelry,  famous  pictures  or 
checks  for  fabulous  sums. 

As  the  disease  advances,  the  writing  becomes  more 
and  more  illegible,  and  when  the  patient  is  unable 
to  make  himself  understood  in  speech,  he  can  no 
longer  write. 

Gait. — In  the  first  stage  of  the  disease  one  unac- 
quainted with  the  patient  might  fail  to  notice  anything 
peculiar  in  his  walk,  but  to  the  trained  eye,  or  to  an 
acquaintance,  a  stiffness  of  gait  is  readily  apparent; 
it  may  seem  only  an  unusual  dignity  of  bearing,  but 
there  is  an  absence  of  elasticity,  the  feet  are  not  raised 
as  much  as  usual,  the  steps  are  shorter  and  quicker, 
the  heels  are  set  down  with  more  force,  and  the  body 
is  held  in  such  a  way  as  to  give  an  observer  the  idea 
that  the  head  must  be  balanced  with  care.  The 
patient  will  find  dithculty  in  stepping  up  into  a  chair; 
he  may  walk  well  on  even  ground  or  on  a  tioor,  but 
stumbles  in  walking  on  uneven  or  unfamiliar  ground, 
or  if  it  be  necessar}^  to  step  over  any  obstruction, 
even  though  seen  perfectly.  Quick  movements,  like 
dancing,  are  impossible.  Going  up  and  down  stairs 
is  troublesome;  the  whole  foot  must  be  rested 
securely  on  each  step  and  a  careful  poise  of  the  body 
must  be  maintained. 

This  impairment  in  coordination  may  be  noticeable 
some  time  before  any  mental  symptoms  appear. 

In  the  second  stage  of  the  disease  the  impairment 
in  gait  is  very  obvious;  even  the  station  is  affected, 
for  the  patient  never  shifts  the  weight  of  the  body 
from  one  foot,  nor  does  he  move  in  an  easy,  careless 
manner,  but  instead  keeps  the  body  firmly  poised  on 
both  feet,  and    in  walking,  often    inclined    to  walk 


Plate  IX. 


i 


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<3 


c? 

^ 


■'i 


t, 


^ 

z:^ 


'<J 


I 

i 


■^ 


<i 


D 


Normal  Gait  Compared  With  the  Gait  of  General  Paresis. 

a,  normal  gait,  the  spaces  are  equal  and  the  feet  follow  the  same  line  of  direction 
d,  paretic  gait,  steps  unequal  in  length,  direction  irregular. 


GAIT.  121 

toward  one  side  when  meaning  to  go  straight  forward. 
The  step  is  now  made  with  a  jerk  at  the  knee,  and 
later,  as  the  knee  grows  stiff,  the  movement  is  from 
the  hip  joint,  giving  a  swaying  motion  to  the  body. 
The  legs  are  kept  somewhat  wider  apart  and  the 
muscular  movements  become  uneven  and  tremulous. 
•  However,  these  symptoms  may  improve  with  quiet, 
or  even  with  a  night's  rest,  so  that  a  physician  seeing 
a  patient  only  occasionally  may  miss  these  accompani- 
ments of  the  disease. 

Toward  the  third  stage  walking  can  be  accom- 
plished only  with  care  and  attention.  Before  start- 
ing the  patient  looks  down  at  his  feet,  is  not  interested 
in  objects  about  him,  but  seems  wholly  occupied  with 
the  effort  of  walking,  and  if  addressed  he  stops  to 
listen  and  answer,  showing  that  he  cannot  walk  and 
talk  at  the  same  time.  If  asked  suddenly  to  turn 
when  going  straight  forward,  he  turns  with  care,  or 
sometimes  sways  like  a  drunken  man. 

The  gait  becomes  more  remarkable  as  the  paresis 
increases;  the  legs  are  dragged  along  the  floor,  often 
unequally,  and  walking  is  accomplished  with  more 
difficulty,  until  towards  the  end  the  knees  fail,  the 
patient  tumbles  frequently  and  at  last  he  cannot 
stand. 

The  muscular  strength  may  still  be  fairly  good  and 
even  when  entirely  unable  to  walk  and  obliged  to 
take  to  his  bed,  the  patient  may  show  considerable 
power  in  muscular  tests.  But  from  the  first  it  is  not 
so  much  muscular  strength  he  lacks  as  power  to 
direct. 

The  different  associations  of  phenomena  in  gen- 
eral paresis  are  of  the  greatest  interest.  One  set  of 
muscles  may  be  more  affected  in  one  case  and 
another  in  another.  Usually  not  until  after  the 
speech  becomes    difficult   are    the    changes    in    gait 


122  PARTICULAR     SYMPTOMATOLOGY. 

observed,  but  the  two  may  occur  together;  or  the 
articulation  may  be  much  impaired,  the  legs  and 
arms  being  scarcely  touched;  or  again,  marked 
ataxia  of  the  legs  may  occur  when  the  articulation  is 
not  at  all,  or  but  slightly  affected.  Moreover,  a  firm, 
elastic  walk  with  full  muscular  vigor  of  limbs  may 
be  found  with  the  exaggerated  deep  reflexes  and  a 
pronounced  irido-motor  paralysis,  or  we  may  see 
either  a  normal  or  an  ataxic  gait  free  from  exagger- 
ated reflexes  and  associated  with  similar  irido-motor 
trouble  (B.  Lewis). 

Like  the  mental  symptoms,  the  motor  symptoms 
may  disappear  almost  entirely  for  a  time. 

A    CASE    OF    GENERAL    PARESIS    WHERE    THE    EARLY 

SYMPTOMS    WERE    MARKED    BY    VERTIGO 

AND    IMPAIRED    GAIT. 

A  patient  required  his  wife's  support  to  prevent  himself 
from  staggering  against  passers-by.  If  alone  he  had  to 
walk  near  a  support.  The  character  of  gait  had  existed 
several  months  before  any  change  in  his  mental  condition 
was  noted.     (Abstract,  Stearns,  Mental  Diseases,  p.  475.) 

Tremor. — Muscular  tremor  affects  all  parts  of  the 
body,  but  before  the  last  stage  it  is  variable  in  differ- 
ent sets  of  muscles;  it  may  be  extreme  in  the  facial 
muscles  or  slight  in  the  extremities,  or  t'eVe  versa,  de- 
pending on  the  location  of  the  lesion.  The  facial  and 
lingual  muscles  are  most  quickly  affected  in  paresis. 
While  attention  is  called  to  the  fact  that  facial  tremor 
seldom  occurs  in  neurasthenia,  cases  do  happen,  and 
may  be  distinguished  from  the  tremor  of  paresis  in 
its  being  less  jerky  than  the  latter,  especially  in  the 
beginning  of  a  voluntary  movement.  A  paretic  in 
protruding  the  tongue  does  it  with  a  slightly  jerky 
movement,  as  if  uncertain  how  much  torce  is  being 
used.     This  movement  may  be  hardly  noticeable  in 


REFLEX    ACTION    AXD    REFLEXES.  1 23 

the  early  morning,  but  is  quite  plain  later  in  the  day- 
after  talking  and  particularly  after  eating.  And  in 
showing  the  teeth,  or  in  wrinkling  the  forehead,  the 
same  ataxic  tremor  may  be  noted  in  these  parts  of 
the  face. 

This  tremor  is  sometimes  called  "  emotional  tre- 
mor," but  incorrectly;  for  while  the  twitchings  of 
the  miuscles  of  the  mouth  may  give  to  the  patient 
the  appearance  of  being  under  emotional  strain 
and  may  suggest  the  coming  of  tears,  frequently  no 
emotional  condition  exists,  or  the  patient  may  be  in 
gay  mood.  This  tremulousness  is  especially  notice- 
able in  the  beginning  of  a  voluntary  effort,  when  the 
paretic  wishes  to  answer  a  question  or  protrude  the 
tongue.  This  tremor  of  the  various  muscles  may  at 
times  seem  slight,  as  compared  with  the  progress  of 
the  disease  marked  b}'  other  S3'mptoms,  while  in 
other  cases  it  may  be  excessive,  as  compared  with 
these  same  symptoms. 

The  disorder  attacks  in  the  beo-inning  the  more 
highly  coordinated  muscles  —  the  lingual  and  facial 
and  those  controlling  the  delicate  movements  of  the 
fingers.  The  control  is  lost,  at  first  only  temporarily, 
but  gradually  the  tremor  becomes  continuous  and  the 
control  passes  almost  entirely  beyond  volition.  Thus 
early  tremors  have  often  a  rapidity  of  ten  vibrations 
per  second,  but  later  they  become  coarser.  The 
larger  groups  of  muscles  become  aftected  and 
towards  the  end  an  extreme  and  constant  tremulous- 
ness accompanies  all  the  voluntary  movements. 

Reflex  Action  and  Reflexes.  —  It  is  seen,  from  a  re- 
view of  the  literature  as  well  as  from  experience, 
that  the  reflexes  do  not  possess  a  uniform  deviation 
in  a  definite  line  as  the  malady  advances. 

The  reflexes  are  at  times  so  enormously  increased 
all   over  the  body  that  a  sudden  puff  of  air  blown 


124  PARTICULAR     SYMPTOMATOLOGY. 

into  the  lace  of  the  patient  may  cause  unusual  reac- 
tion. Clouston,  Mickle  and  Folsom  especially  refer 
to  this  condition. 

A    CASE    OF    EXCESSIVE    REFLEX    EXCITABILITY. 

In  G.  M.  general  paralysis  hegan  with  aphasia.  As  he 
began  to  speak,  the  peculiar  articulation  was  noticed  and 
he  died  in  about  two  years.  In  this  case,  the  motor  reflex 
excitability  of  the  brain  and  cord  was  greater  than  I  have 
ever  seen  in  any  case  whatever.  A  very  slight  tap  on  the 
toe  would  set  up  a  convulsion,  first  in  that  leg,  and  then 
in  the  next,  a  slight  puff  suddenly  into  his  face  would 
make  him  jump  wholly  off  his  seat.  (Abstract,  Clouston, 
o^.  ct't.,  p.  400.) 

The  superficial  reflexes  may  be  lessened,  lost,  or 
increased  at  any  period;  as  a  rule,  the  skin  reflexes 
are  often  lessened  or  lost,  which  is  particularly  the 
condition  in  the  last  stage. 

Bianchi  and  Bettencourt-Rodrigues  (vide  Mickle) 
observed  that  in  general  paresis,  expansive  mental 
symptoms  correspond  to  exaggerated  reflexes,  mental 
depression  to  lessened  or  abolished  reflexes.  But  in 
the  early  stage  of  a  typical  case  are  exaggerated  knee- 
jerks,  and  lessened  or  lost  plantar  reflex;  and  the 
early  exaggeration  of  reflexes  is  supposedly  related 
to  the  congestion,  excitement,  functional  dynamic 
quasi-exaggeration  of  the  early  stages  of  general 
paresis. 

Lewis  and  others  give  exaggeration  of  the  knee- 
jerk  as  the  more  frequent  phenomenon;  although 
they  may  be  temporarily  or  permanently  increased, 
normal,  lessened  or  lost.  He  adds  that  it  may  be 
simply  a  functional  disturbance,  transient  only,  in- 
duced by  nervous  discharges  from  the  cerebral  cor- 
tex. If  temporary,  it  is  often  found  as  the  immediate 
result  of  a  congestive  seizure.     On  the  other  hand, 


REFLEX    ACTION    AND    REFLEXES.  1 25 

it  may  be  a  sign  of  organic  disease  of  the  spinal 
cord,  with  accompan34ng  symptoms  of  descending 
sclerosis.  "It  is  important,"  he  says,  "to  note  that 
we  have  as  associated  phenomena  in  many  cases  ot 
general  paralysis,  a  firm  elastic  walk,  with  full 
muscular  vigor  of  limbs,  exaggerated  deep  reflexes, 
and  pronounced  irido-motor  paralysis." 

The  jerk  may  difter  in  the  two  limbs.  It  often 
varies  in  quickness  in  different  cases  and  in  reaction 
time.  The  superficial  and  the  deep  reflexes  are  often 
dissimilarly  aftected  in  the  same  patient  at  the  same 
examination.  The  reflexes  vary  greatly  under  con- 
ditions of  rest,  fatigue  and  excitement.  In  the 
tabetic  form  of  general  paresis  the  knee-jerk  is 
usually  absent  or  diminished,  although  it  may  be 
normal  or  increased.  As  a  general  rule,  when  the 
patellar  reflexes  are  absent,  the  plantar  reflexes  are 
also  either  absent  or  diminished. 

Mickle  groups  with  the  absent  and  exaggerated 
knee-jerks  certain  definite  symptoms :  "  With  absent 
knee-jerk  a  relatively  larger  share  of  pain,  wet  habits, 
hallucinations  (and  slightly,  of  epileptiform  seizures 
and  ataxiform  gait) ;  and  lessened  feeling  of,  and  motor 
reaction  to,  pinches  and  tickling  of  the  feet.  And,  on 
the  other  hand,  with  exaggerated  knee-jerk  a  large, 
almost  exclusive,  share  of  quasi-syncopal  seizures, 
and  much  jerk  and  spasm  in  movement."  Pickett,^ 
in  a  clinical  study  of  one  hundred  and  forty-nine 
cases  occurring  at  the  Philadelphia  Hospital  found 
that  the  relative  condition  of  the  knee-jerks  in  the 
entire  series  was  in  the  following  proportion:  In- 
creased in  49  per  cent,;  diminished  in  lo  per  cent.; 
absent  in  31  per  cent.,  and  normal  in  10  per  cent. 

Under  eye  symptoms  will  be  found  pupillary  re- 
flexes. 

iThe  Philadelphia  Medical  Journal,  Vol.  9,  p.  581. 


126  PARTICULAR     SYMPTOMATOLOGY. 

A    CASE     OF    GENERAL    PARESIS    WITH     "CROSSED 
REFLEXES." 

Male,  ast.  55,  with  the  usual  mental  and  physical  signs 
of  general  paralysis.  "Crossed  reflexes  "  were  noticed 
after  the  disease  had  advanced  to  the  stage  that  compelled 
the  patient  to  be  kept  continually  in  bed.  At  this  time,  in 
addition  to  the  exaggerated  knee-jerks,  it  was  noticed  that 
the  patellar  tendon  was  associated  with  a  contraction  over 
the  outer  and  upper  part  of  the  opposite  thigh  in  front. 
This  crossing  occurred  with  both  knee-jerks,  but  the  con- 
traction was  more  on  the  right  thigh  than  on  the  left.  The 
same  crossed  contractions  were  associated  with  the  plantar 
reflexes.  Ankle  clonus  was  faintly  present,  but  there  was 
not  an}^  crossing.  There  was  no  crossing  with  the  other 
reflexes.  The  interscapular,  abdominal  and  epigastric 
were  absent,  the  gluteal  brisk,  cremasteric  faint  and  pu- 
pillar}^  sluggish.  (Abstract,  Cottom,  American  Journal  of 
Psychology,  Vol.  5,  p.  84.) 


CHAPTER   XI. 

PARTICULAR    SYMPTOMATOLOGY    {continued^. 

After  the  onset  of  the  established  disease  many  of 
the  patients  are  subject  to  episodes  of  cerebral  origin. 
These  attacks  comprise  apoplectic,  convulsive  and 
paralytic  seizures.    Lewis  designates  them  as  follow^s  : 

Syncopal  or  quasi-synco-  Epileptiform  discharges, 
pal  attacks. 

Petit  mal,  or,  exception-  Apoplectiform,     or     true 

ally,  grand  mal.  congestive,  attacks. 

Limited,  or  unilateral,  Plemiplegia  and  mono- 
twitching,  plegia. 

Syncopal  Attacks. — Vertigo,  or  "  slight  faintness," 
is  often  the  first  indication  recognized  by  the  patient 
and  his  friends,  at  the  onset  of  the  disease.  The  pa- 
tient does  not  lose  consciousness,  but  feels  disposed 
to  sit  down  to  rest  for  a  few  minutes.  These  attacks 
are  referable  to  a  spasm  of  the  vaso-constrictor  nerves 
of  the  pial  vessels,  with  subsequent  damming  back  of 
the  returning  blood,  with  irritation  of  the  nervous  ele- 
ments. 

Syncopal  attacks  are  by  no  means  uncommon,  dur- 
ing the  course  of  general  paresis,  and  often  are  the 
first  signs  of  a  failing  circulation.  A  patient,  after 
eating,  suddenly  blanches  and  falls  forward;  his  pu- 
pils are  dilated,  his  pulse  feeble,  his  skin  becomes 
cold  and  damp;  no  convulsions  follow  and  shortly  he 
rallies  and  recovers  his  former  condition. 

127 


128  PARTICULAR    SYMPTOMATOLOGY. 

GENERAL    PARESIS    BEGINNING    WITH    VERTIGO. 

A  case  in  which  the  first  indication  recognized  was  an 
attack  of  vertigo  and  sHght  faintness  requiring  the  pa- 
tient, at  his  store,  to  sit  down  for  a  few  minutes.  He  did 
not  lose  consciousness,  soon  arose  and  going  to  his  doc- 
tor, explained  the  character  of  the  attack.  During  sev- 
eral months,  he  had  no  such  further  attacks.  Somewhat 
overheated  and  fatigued  at  noon  in  June,  he  laid  down  to 
sleep.  After  a  short  time,  he  awoke  in  a  dehrious  condi- 
tion, in  which  he  continued,  a  part  of  the  time,  greatly 
excited  for  three  or  four  weeks.  The  delirium  and  excite- 
ment then  gradually  passed  away,  leaving  the  mind  at 
times  confused  and  with  delusions  of  miportance.  He  has 
had  no  attacks  approaching  the  nature  of  an  epileptiform 
seizure  or  loss  of  consciousness  or  even  vertigo,  to  the 
present  time,  a  period  of  nine  months,  though  other  symp- 
toms are  well  marked.  (Abstract,  Stearns,  Mental  Dis- 
eases, p.  474.) 

A    VARIETY    OF    CEREBRAL    SEIZURE    IN    WOMEN    SIMULAT- 
ING   KATATONIC    SYMPTOMS. 

Naecke  observed  three  paretic  women  who  had  repeated 
attacks  of  stupor  with  muscular  tension.  They  became 
speechless,  head  bent  forward,  face  pale  and  expression- 
less, eyes  wide  open,  staring  into  vacancy  ;  they  seemed 
without  comprehension,  had  to  be  fed  and  forced  to  move. 
Both  stupor  and  muscular  tension  usually  disappeared  in  a 
few  hours.  (Abstract,  American  Journal  of  Insanit}',  Vol. 
50,  p.  79-) 

GENERAL    PARESIS    DEVELOPING    IN    A    MAN    SUBJECT    TO 
SYNCOPE    FROM    INFANCY. 

A  patient,  42  on  admission,  had  syjicope  from  his  infancy, 
on  the  least  annoyance ;  he  became  pale,  fell  down  and 
lost  consciousness,  and  on  coming  to,  he  would  have  severe 
headache.  He  conducted  an  important  business  and  had 
three  children.  His  mother  and  brother  presented  the 
same  symptoms.  While  in  asylum,  he  had  no  syncopal 
attack.     (Abstract,  Christian,  loc.  cit.,  p.  496.) 


APOPLECTIFORM    ATTACKS.  1 29 

Apoplectiform  Attacks. — It  is  not  always  possible  to 
separate  sharpl}*  in  clinical  work  the  various  forms 
of  cerebral  seizures,  but  there  is  an  apoplectic  type, 
which  maybe  associated  with  slight  convulsive  move- 
ments, although  not  so  necessarih'.  These  attacks  are 
less  frequent  than  the  epileptiform  seizures.  Pre- 
monitions may  be  present  or  absent,  while  the  attacks 
var}"  in  degree  from  the  slightest  symptoms  to  those 
of  the  most  extreme  type.  The  symptoms  are  as 
follows:  There  is  generally  a  precedent  rise  of  tem- 
perature, expressed  in  a  congestion  of  the  face  with 
heated  skin.  The  pupils  may  be  dilated.  Paral3'sis, 
especially  of  the  unilateral  form,  follows,  with  pos- 
sibly conjugated  deviation  of  the  eyes  with  rotation 
of  the  head.  The  condition  simulates  pathologically 
the  ph3'siological  action  of  the  nitrite  of  amyl.  The 
patient  has  observed  for  some  time  that  his  head 
feels  dull  and  heavy,  he  experiences  sudden  rushes 
of  blood  to  the  head,  his  temporals  beat  violently 
and  for  the  moment  he  is  unable  to  speak  or  even 
think.  These  attacks  may  occur  at  anytime;  they 
may  be  so  slight  as  to  cause  scarcely  an}^  interruption 
of  the  flow  of  ideas,  or  they  may  resemble  apo- 
plexies, due  to  extensive  hemorrhage. 

Tetanoid  seizures  ma}'  occur,  with  tonic  spasm  of 
the  muscles  of  the  chest  and  neck,  resembling  epilep- 
tiform seizures.  Pleurothotonos  and  even  opisthot- 
onos ma}'^  be  present.  Hysteroid  waves  occur, 
chiefl}^  in  women,  but  in  inen  there  may  appear  un- 
controlled emotional  outbreaks. 

The  import  of  the  apoplectic  seizures  is  even 
graver  than  that  of  the  epileptiform.  One  of  the  chief 
dangers  to  the  patient  is  from  pneumonic  hypostasis. 

GENERAL    PARESIS    WITH    REPEATED    ATTACKS    OF 
CEREBRAL    SEIZURES. 

Mr.  X.,  get.  41;  single;  grocer.     His  father  died,  aet. 


130  PARTICULAR    SYMPTOMATOLOGY. 

83,  of  urethral  fever;  his  mother,  £et.  50,  of  cancer.  One 
half  brother  has  had  a  systematized  hypochondriacal  delu- 
sion for  some  years.  A  half  sister  has  been  neurotic  and 
her  husband,  a  second  cousin,  committed  suicide  while  suf- 
fering from  nervous  depression.  A  daughter  of  this  sister 
has  been  hysterical  for  some  years  and  has  been  almost 
insane  for  some  time.  Another  half  sister,  by  another 
wife,  and  born  after  the  father  was  sixty  years  old,  is  neu- 
rotic with  intense  egotism  and  slight  intellectual  imperfec- 
tion in  the  form  of  inertia  and  absence  of  ambition.  The 
only  brother  of  the  patient  is  sound,  mentally  and  physic- 
ally. His  paternal  grandfather  was  a  confirmed  alcoholic. 
His  maternal  grandparents  were  healthy.  Mr.  X.  was  not 
peculiar  during  childhood  and  youth  except  morbidly  sen- 
sitive to  criticism  and  would  seclude  himself  if  offended  or 
disappointed.  He  was  successful  at  business  and  very 
much  liked.  His  business  was  destroyed  by  fire  and  he 
became  very  poor.  He  disappeared  for  a  year,  and  when 
found  he  was  penniless  and  very  much  run  down.  He 
would  nol  tell  anyone  what  he  had  been  doing.  His  rela- 
tives found  him  employment.  Twenty-two  years  ago  he  was 
under  treatment  for  the  alcohol  habit ;  for  two  years  before 
admission  he  indulged  in  sexual  excess  and  has  suffered 
from  nocturnal  incontinence  of  urine,  and  recently  from 
imperfect  control  of  the  vesical  sphincter  during  the  day. 
A  year  ago  in  July,  he  had  an  attack  of  numbness  in  the 
left  side  and  has  had  over  ten  similar  attacks  since,  result- 
ing in  a  paresis  of  that  side  ;  also  he  began  to  have  difficulty 
in  articulation,  especially  if  fatigued  or  excited.  Within  the 
last  six  months,  his  spelling  has  become  worse  ;  he  omits 
words  in  writing  or  dates  letters  wrongly  ;  his  penmanship 
varies  :  part  of  it  is  in  a  fair  round  hand  and  part  of  it  is  a 
dragging  scrawl ;  some  words,  begun  well,  end  in  a  con- 
fused blur.  The  letter  is  not  signed.  He  is  unable  to  add 
a  considerable  column  of  figures  in  his  accounts  and  often 
drops  an  important  item.  Within  three  months,  his  ideas 
have  become  confused  and  he  cannot  think  clearly  ;  he  lost 
his  way  in  Boston  where  he  is  perfectly  at  home.  At  a  junc- 
tion, he  got  out  of  a  car  and  then  got  into  it  again,  thinking 


APOPLECTIFORM    ATTACKS.  I3I 

he  had  made  the  change.  He  cannot  relate  facts  as  they 
occurred  or  as  they  were  told  him.  He  severely  hurt  his 
foot  by  a  fall,  a  few  months  ago,  during  a  paretic  attack. 
Recently,  his  temper  has  been  excited  violentl}'  by  trivial 
things  :  in  speech  and  manner  only,  however,  and  he  has 
never  threatened  injur}^  to  anj'one.  His  statements  are 
usually  wholh'  unreliable.  The  night  before  admission, 
he  was  found  sitting  on  the  front  steps  with  nothing  on  but 
a  shirt,  having  thrown  his  pantaloons  into  the  street.  On 
admission,  well  nourished  ;  appetite  good  ;  bolts  his  food  ; 
bowels  constipated  ;  urine  negative  :  heart  action  regular 
but  weak:  pulse  96:  tongue  edematous,  fissured,  with- 
out coating,  very  tremulous  w^hen  protruded  ;  speech  hesi- 
tating ;  Unguals  pronounced  with  difficulty  ;  facial  muscles 
brought  into  play  in  talking  ;  pupils  react  to  light  but  there 
is  commencing  atrophy  of  the  retina.  There  is  quanti- 
tative electrical  change  in  the  muscular  S3'stem  generally 
and  in  the  left  leg  especially.  He  is  very  self-conscious, 
irritable  and  suspicious.  During  the  first  month's  residence 
his  general  condition  improved  but  he  became  very  hypo- 
chondriacal, thinking  the  various  paresthesi^e  were  or- 
ganic complaints  in  the  parts.  He  had  a  slight  apoplecti- 
form attack  in  the  early  part  of  the  month ;  during  the 
latter  part,  he  developed  modified  delusions  of  grandeur 
concerning  his  own  identity  and  his  possessions.  During 
the  next  month,  he  had  two  apoplectiform  attacks,  one  of 
them  with  motor  aphasia  lasting  an  hour.  His  incontin- 
ence was  present  night  and  day  :  gait  more  ataxic  ;  failure  " 
of  memory  more  marked.  During  the  next  month  he 
was  exalted,  showing  explosive  and  boisterous  mirth,  or 
anger  for  trivial  causes.  During  the  next  three  months  he 
had  three  paretic  attacks,  each  one  leaving  the  left  side 
weaker  and  his  ataxia  more  marked.  He  heard  voices  at 
night  ridiculing  him.  With  the  last  paretic  attack,  there 
was  ptosis  of  left  eyelid,  with  anesthesia  and  absence  to 
response  to  either  electrical  current  on  the  left  side.  There 
was  progressive  physical  failure,  rapid  mental  reduction, 
loss  of  memory  for  recent  events  and  great  confusion  of 
thought.     At  the  end  of  the  period  he  could  not  get  up  or 


132  PARTICULAR    SYMPTOMATOLOGY. 

down,  dress  or  undress  :  he  could  walk  in  a  straight  line 
if  started,  but  fell  if  he  attempted  to  turn.  In  the  morning, 
he  could  articulate  fairly  well  and  write  connected  sen- 
tences, but  his  ability  decreased  during  the  day,  so  that 
by  evening  he  could  do  neither.  He  also  had  temporary 
paresis  of  the  vocal  cords,  making  his  voice  husky  for  a 
day  or  two.  At  times,  there  was  complete  aphonia.  Dur- 
ing the  next  two  months  there  was  no  change  except  that 
he  thought  there  was  some  one  in  his  room  impersonating 
him.  He  could  see  and  hear  some  one.  He  said  that  this 
strange  man  put  him  out  of  bed  and  was  trying  to  steal  his 
clothes.  This  delusion  persisted  for  a  long  time,  grad- 
ually merging  into  the  idea  of  dual  personality,  with  whom 
he  kept  up  an  almost  continuous  conversation.  This  idea 
disappeared  only  when  the  mental  reduction  had  reached 
the  degree  necessary  to  abolish  it.  At  the  end  of  the  next 
two  months,  he  was  eating  heartily  but  carelessly,  bolting 
his  food  ;  not  sleeping  well ;  no  change  in  the  motor  par- 
esis, can  walk  fairly  well  but  cannot  get  up.  A  week 
later,  his  mirror  had  to  be  removed  to  prevent  his  breaking 
it  in  efforts  to  get  at  the  person  who  was  disturbing  him. 
During  the  day,  he  is  in  constant  communication  with  his 
double,  who  tells  him  he  is  going  to  die  of  starvation. 
The  lingual  and  laryngeal  paralysis  is  progressing,  so  that 
he  speaks  only  in  a  low  monotone.  In  a  year  and  a  half, 
he  was  entirely  demented  and  helpless.  The  left  side  was 
entirely  paral3'zed.  (Abstract,  Tomlinson,  Journal  of  Ner- 
vous and  Mental  Diseases,  Vol.  16,  p.  766.) 

GENERAL  PARESIS   BEGINNING  WITH   CONGESTIVE  SEIZURE. 

Robert  M.,  ast.  34,  stupid,  mentallv  clouded,  had  hallu- 
cinations of  hearing,  heard  people  telling  him  to  do  things  ; 
tongue  tremulous  ;  left  pupil  larger  than  right ;  plantar  and 
knee  reflexes  exaggerated.  Mentally  the  patient  cleared 
up  and  was  discharged  ;  a  few  months  later  he  returned 
with  marked  motor  symptoms  of  rapidly  advancing  signs 
of  general  paresis.  He  probably  had  had  a  congestive 
attack  and  was  recovering  from  it  before  admission.  (Ab- 
stract, Campbell,  Clark  Mental  Diseases,  p.  221.) 


EPILEPTIFORM     ATTACKS.  1 33 

Epileptiform  Attacks.  —  Cerebral  congestion  may 
appear  at  the  outset  of  the  disease,  as  well  as  ter- 
minate it  in  its  later  stages.  It  may  be  looked  for  at 
any  time  in  the  course  of  the  disease.  One  of  the 
most  serious  forms  of  congestion  is  the  epileptiform 
attack.  There  is  a  sudden  loss  of  consciousness  with 
the  typical  warning  cry,  pallor  followed  by  flushing, 
foaming  at  the  mouth  and  convulsions.  These  con- 
vulsions may  be  general,  or  limited  to  one  side,  or  even 
one  limb.  The  temperature  usually  rises,  even  to  the 
height  of  103°  to  104°.  These  attacks,  as  a  rule, 
are  not  isolated,  but  occur  in  sequence,  separated  by 
longer  or  shorter  periods  of  coma,  even  amounting 
to  a  regular  status  epilepticus. 

Mental  deterioration  invariably  follows ;  the  condi- 
tions are  aggravated  and  death  often  occurs  in  the  at- 
tack. The  prolonged  rise  of  the  temperature  points 
to  this  contingency.  Some  complication  is  generally 
left  behind,  such  as  hemiplegia,  aphasia,  paresis,  if 
death  does  not  actually  ensue. 

It  is  a  grave  condition,  which  must  always  be  at- 
tended with  the  gloomiest  forebodings.  It  is  re- 
garded rather  as  a  symptomatic  epilepsy  than  true 
epilepsy,  although  clinically  it  shows  no  essential 
difference.  These  attacks  may  occur  early  in  the 
disease,  but  generally  not  until  a  year  has  elapsed. 
According  to  Newcombe,  out  of  one  hundred  general 
paretics,  fifty-one  had  epileptiform  seizures,  but  only 
one  had  convulsions  within  three  months  of  the 
onset. 

Lewis,  who  has  studied  this  condition  carefully, 
believes  that  the  onset  of  the  attack  is  almost  invari- 
ably hemispheric,  i.  e.,  that  the  convulsions  begin 
unilaterally  and  may,  or  may  not,  spread  to  the  op- 
posite side;   that  they  are  often  preceded  by  a  well- 


134  PARTICULAR    SYMPTOMATOLOGY. 

marked  tonic  stage,  as  the  rapid  primary  discharges 
occur;  that  the  clonic  stage,  being  often  long  pro- 
tracted, becomes  more  and  more  broken  up  into  in- 
tervals of  comparative  rest,  until  at  last  an  occasional 
convulsive  jerk  of  the  limb,  or  separate  muscular 
contractions  alone  prevail. 

GENERAL    PARESIS    BEGINNING    WITH    CONVULSIONS. 

A  porter  had  been  promoted  to  a  position  where  greater 
responsibilities  and  labors  of  a  mental  character  were 
thrown  on  him  ;  in  the  midst  of  apparent  health,  having 
been  slightly  worried,  he  was  seized  with  a  convulsion, 
lasting  several  hours  with  partial  consciousness  and  later 
these  convulsions  occurred  in  status-like  succession  at 
intervals  of  a  week  for  some  months.  Eighteen  months 
after,  the  convulsions  having  been  absent  for  a  year,  he 
died  with  the  quiet  type  of  paresis.  (Abstract,  Spitzka 
on  Insanity,  p.  205.) 

GENERAL    PARESIS    BEGINNING    WITH    CONVULSIONS. 

One  of  my  patients  had  many  epileptic-looking  fits  for 
a  year,  and  was  treated  for  epilepsy  by  eminent  physicians 
during  that  time  before  the  usual  mental  and  motor  signs 
of  general  paralysis  appeared.  (Abstract,  Clouston,  Men- 
tal Diseases,  p.  393.) 

GENERAL     PARESIS    WITH     CONVULSIONS.       A    DESCRIPTION 
OF    THE    EPILEPTIFORM    SEIZURE. 

J.  F.,  seized  with  convulsions  which  occur  every  ten  or 
fifteen  minutes,  are  identical  with  epileptic  seizures,  except 
that  the  convulsions  are  chiefly  unilateral,  involve  the 
chest  muscles  but  slightly  ;  no  lividity  of  face  or  obstructed 
breathing  ;  each  attack  lasts  for  about  thirty  seconds.  The 
convulsive  phenomena  in  their  sequent  stages  were  as  fol- 
lows :  (i)  No  pallor,  but  head  and  eyes  deviate  to  right, 
a  broken  inarticulate  cry,  pupils  dilate  widely,  brow  is 
raised ;  (2)  mouth  drawn  to  right,  lips  twitch  strongly  and 


EPILEPTIFORM     ATTACKS.  1 35 

uncover  the  canines  ;  (3)  right  arm  flexed,  with  forefinger 
extended,  then  raised  and  convulsively  jerked  at  shoulder, 
brow  twitches  violently ;  (4)  in  certain  seizures,  the  dis- 
charge spread  to  right  leg  also,  but  did  not  involve  the 
left.  After  the  fit,  there  was  paralytic  deviation  of  head 
and  eyes  to  the  left,  and  helplessness  of  right  arm,  left 
pupil  large,  but  slowly  regained  former  size,  champing 
movements  of  the  jaw,  no  exaggeration  of  patella  reflex, 
no  ankle  clonus.  At  the  onset  of  each  attack,  the  heart, 
previously  beating  strongly,  became  imperceptible  during 
the  tonic  stage.  The  cry  always  precedes  each  attack. 
(Abstract,  Lewis,  of.  ctt.,  p.  295.) 


A    CASE    WITH    EPILEPTIFORM    SEIZURES. 
RAPID    COURSE. 

John  W.,  ast.  45,  first  symptoms,  restlessness  at  night, 
which  is  a  frequent  first  warning,  epileptiform  fits  followed. 
Sexual  desire  very  strong  but  could  not  be  gratified. 
Naturally  temperate  and  careful  of  money.  Slight  ac- 
cident to  left  foot  two  years  previously.  Tabetic  gait, 
weaker  on  left  side ;  grip  jerky  and  spasmodic  in  left 
hand ;  speech  slow,  interrupted  and  slurred ;  absence  of 
tendon  reflex ;  left  eye  blind  from  injury.  Died  a  year 
after  admission.  (Abstract,  Campbell  Clark,  of.  ctt.,  p. 
221.) 

A    CASE    OF    GENERAL    PARESIS    OF    THE    CON- 
VULSIVE   FORM. 

G.  E.,  aet.  40.  He  was  of  an  excitable  disposition  ;  he  has 
led  a  dissipated  life  in  regard  to  drink  and  women  ;  of  a  fiery 
temper  ;  he  had  had  syphilis,  and  much  mental  excitement. 
He  had  complained  for  some  time  of  severe  headache,  and 
insomnia  ;  he  was  unusually  irritable,  and  not  fit  to  do  a  day's 
business.  One  day  he  suddenly  fell  down  in  a  fit,  and 
remained  in  general  and  severe  convulsions  with  complete 
unconsciousness  for  about  two  hours  and  died  in  them. 
After  death  there  were  all  the  pathological  signs  of  gen- 
eral paralysis,  especially  the  adherence  of  the  pia  to  the 


136  PARTICULAR    SYMPTOMATOLOGY. 

convolutions  of  the  vertex.  There  was  no  localized  disease 
of  the  membranes  or  vessels  that  was  recognized  as  syphi- 
litic and  he  had  not  been  drinking  heavily  before  his 
death.      (Abstract,  Ciouston,  of.  cit.,  p.  392.) 

Unilateral  Twitching. — Limited  or  unilateral  twitching 
of  the  muscles  of  the  face  or  of  certain  groups  of  muscles, 
such  as  those  of  the  hand,  or  of  the  thumb  and  fingers  is 
not  infrequent.  These  convulsive  jerks  are  usually  of 
short  duration,  but  they  are  sometimes  prolonged  over 
hours,  or  even  days.  The  rhythmic  jerks  may  be  on  both 
sides  but  generally  they  are  unilateral. 

A    CASE    OF    GENERAL    PARESIS    WITH    MARKED 
TWITCHINGS. 

G.  C.  D.  had  intense  irritability  and  continual  mental 
excitement  lasting  for  many  months,  together  with  jerking 
of  the  limbs  ;  especially  of  the  arms,  so  that  the  attempt  to 
perform  any  purposive  action  would  cause  them  to  be  jerked 
violently  about,  rendering  the  efforts  quite  futile.  When 
sitting  quietly,  a  touch  on  the  arm  would  set  both  violently 
jerking,  and  sometimes,  there  would  be  ceaseless  twitch- 
ing of  the  arms  and  legs  all  day.  (Abstract,  Turner,  John, 
Journal  Mental  Science,  Vol.  35,  p.  343.) 

A    CASE    MARKED    BY    CONVULSIVE    TWITCHING. 

J.  S.,  general  paralytic,  was  seized  with  convulsive  twitch- 
ings  of  the  limbs  ;  face  was  flushed  and  skin  covered  with 
a  greasy  unctuous  sweat.  Both  arms,  especially  the  left, 
continually  and  consentaneously  jerked  by  the  convulsive 
twitching  of  the  extensor  group  of  the  elbow  and  wrist ; 
the  fingers  of  the  left  hand  are  suddenly  spread  as  in  the 
act  of  playing  the  pianoforte  ;  the  toes  show  a  tendency  to 
"spread,"  the  feet  being  rigidly  extended,  while  there  is 
also  continuous  clonus  of  both  ankles,  especially  increased 
by  flexion  of  the  foot ;  if,  during  a  period  of  partial  ces- 
sation of  this  clonic  state,  the  sole  be  irritated  by  a  pin, 
clonus  is  again  briskly  established.  There  is  a  notable 
degree  of  the  "  paradoxical  contraction."     The  superficial 


EYE    SYMPTOMS.  137 

abdominal  reflexes  are  dulled.  Tache  cerebrale  is  rapidly- 
produced  and  is  vivid  over  all  parts  of  the  body.  Both 
conjunctivas  are  injected,  both  pupils  show  mydriasis  but 
the  left  is  larger,  both  are  fixed  to  a  bright  beam  of  light. 
Bowels  and  bladder  paralyzed.  The  patient  was  greatly 
demented  and  quite  mute.  The  next  day  twitching  was 
limited  to  left  foot  and  hand,  and  there  was  the  same  ex- 
pansive movement  of  the  digits.  Five  days  later,  convul- 
sive twitching  of  left  hand  and  foot  was  unchanged,  and 
plantar  reflex  greatly  exaggerated  and  hypersensitive. 
Five  months  later,  the  above  movements  have  continued 
to  date,  but  are  gradually  declining.  (Abstract,  Lewis, 
o^.  cit.,  p.  296.) 

A    CASE    OF    GENERAL    PARESIS    IN    W^HICH    PROTRUSION    OF 
TONGUE    PRODUCED    FACIAL    SPASMS. 

A  patient  with  general  paresis  could  not  protrude  his 
tongue  without  inducing  violent  left  facial  spasms,  the 
tonic  twitchings  being  associated  with  much  vaso-motor 
paresis.     (Abstract,  Lewis,  o^.  cit.,  p.  291.) 

Eye  Symptoms.  —  The  ocular  changes,  occurring 
during  the  course  of  paresis,  are  numerous  and  varied. 
None  of  them  is  found  in  all  cases;  nor  are  they 
essentially  a  part  of  the  disease,  but  some  one,  at 
least,  is  present,  as  a  rule. 

Most  prominent,  and  manifest  to  the  superficial 
observer,  is  the  alteration  in  the  general  expression 
of  the  eye.  This,  vv^hen  found,  is  pathognomonic. 
It  is  difl&cult  to  express  the  change  in  vv^ords,  but  its 
salient  characteristic  is  a  lack  of  vivacity  and  a  dull, 
lifeless  appearance  of  the  cornea. 

The  important  symptoms,  however,  are  those  due 
to  changed  conditions  of  the  oculo-motor  apparatus. 
In  a  small  number  of  cases  the  extrinsic  muscles  will 
be  found  affected,  giving  rise  to  the  various  forms  of 
strabismus,  ptosis,  or  even  nystagmus.     On  the  other 


138  PARTICULAR     SV.MPTO-MATOLOGY. 

hand,  in  the  great  majority  of  cases,  the  intrinsic 
muscles,  governing  the  size  of  the  pupil  and  the 
movements  of  the  iris,  are  in  some  way  involved. 

Frequently  there  is  found  an  extremely  myotic 
condition  of  one  or  both  pupils,  known  as  the  pin- 
point pupil,  being  due  to  a  spastic  condition  of  the 
muscle  fibers  of  the  iris,  which  govern  contraction. 
Associated  with  this  small  pupil,  there  is  complete 
absence  of  movement  of  the  iris  upon  exposure  to 
light,  nor  does  the  pupil  dilate  when  the  eye  is 
shaded.  This  condition  is  said  by  man}'  authors  to  be 
a  characteristic  of  the  earlier  stage  of  the  disease,  but 
it  may  and  frequently  does  persist  throughout  the 
entire  illness.  This  contracted  pupil  is  also  found  in 
locomotor  ataxia  and  other  spinal  affections  and  it  is 
always  seen  in  paretics  of  the  tabetic  class.  It  may 
be  unilateral,  giving  rise  to  a  decided  inequality  01 
the  pupils,  which  is  due  to  an  accompanying  paral3'sis 
of  the  dilator  fibers  in  the  other  iris.  Of  course  all 
local  inflammations  and  changes,  otherwise  causing 
this  condition,  should  be  rigidly  excluded. 

A  widely  mydriatic  pupil,  due  to  paralysis  of  the 
sphincter  muscles,  unilateral,  or  on  both  sides,  is  more 
frequently  found  in  the  later  stages  of  the  disease, 
but  may  occur  at  any  part  of  its  course.  Various 
irregularities  in  the  shape  of  the  pupil,  also,  are  seen. 
It  is  to  be  remembered  that  adhesions  and  local 
causes  should  be  sharplv  differentiated. 

Among  the  anomalies  of  the  various  ocular  re- 
flexes  the  absence  of  the  sympathetic  dilatation,  fol- 
lowing irritation  of  the  skin  at  the  side  of  the  neck,  is 
the  one  earliest  observed  and  it  is  one  that  is  most 
commonly  found.  In  nearly  fifty  per  cent,  of  all 
cases  there  is  a  disappearance  of  the  consensual  re- 
flexes, always  in  connection  with  the  impairment  of 
the   light  reflex.     Reflex  iridoplegia,  or  the  Argyll- 


Plate  VIIU. 


RIGHT  IRIDOPLEGIA  .DILATATION  OF  RIGHT   PUPIL  i.     i  Mills. 1 


EYE    SYMPTOMS.  1 39 

Robertson  pupil,  is  often  present,  and  if  noted  in  the 
earl}^  stages  of  paresis  is,  as  in  tabes,  a  very  important 
symptom.  There  may  be  a  complete  absence  of  re- 
sponse to  all  efforts  at  accommodation,  as  well  as  to 
stimulation  by  light,  including  the  failure  to  react  to 
movements  of  divergence  and  convergence. 

As  was  before  stated,  any  or  all  of  these  conditions 
may  be  found  at  some  stage  of  the  disease,  while 
none  are  necessarily  present.  The  dilated  pupil  is 
more  often  found  than  the  abnormally  contracted  one. 
The  light  reflex  is,  in  many  cases,  entirely  lacking 
and  at  least  a  noticeably  sluggish  reaction  is  found  in 
almost  all  cases.  The  movements  of  the  iris,  during 
efforts  at  accommodation,  are  affected,  as  a  rule,  in  the 
latest  stages  of  the  disease,  while  in  a  large  number 
of  cases  there  is  a  perfectly  normal  response. 

These  changes  are  apt  to  affect  the  two  pupils  in  a 
varying  degree,  or  they  may  be  found  only  in  one, 
the  other  approaching  the  normal,  so  that  in  the  great 
majority  of  cases  a  decided  difference  in  the  degree 
of  response  to  stimulus  is  observed.  The  pupils  are 
not  only  often  unequal  in  size  and  irregular  in  con- 
tour, but  these  irregularities  vary  considerably  at  dif- 
ferent times,  a  dilated  pupil  in  the  morning  becoming 
a  contracted  one  later  in  the  day.  So,  too,  the  irregu- 
larity of  contour  may  change  from  one  pupil  to  the 
other,  if  not  constant  in  both. 

There  is  sometimes  a  progressive  failure  of  the 
power  of  vision,  either  partial  as  for  colors  or  dis- 
tances, or  general  and  entire,  from  involvement  of 
the  optic  nerve.  Atrophy  of  the  optic  nerve  has 
been  observed  among  the  early  manifestations  of 
paresis  and  the  failure  of  vision  has  sometimes  been 
a  premonitory  symptom  of  the  disease,  occurring  sev- 
eral months  or  years  before  any  of  the  more  definite 
and  characteristic  signs. 


140  PARTICULAR    SYMPTOMATOLOGY. 

Distinct  optic  neuritis  is  not  commonly  found,  the 
changes  being  due  to  a  dimness  of  outline  of  the  disc 
and  a  fullness  of  the  blood-vessels.  As  a  rule,  the 
vision  of  the  patient  is  not  markedly  affected  by  this 
condition,  and  v^^here  there  is  a  decided  failure  of 
sight,  there  are  usually  associated  with  this  condition, 
lesions  of  a  tabetic  or  lateral  sclerotic  nature  and  the 
accompanying  symptoms. 

GENERAL     PARESIS     BEGINNING     WITH     RETINAL     DISEASE. 

G.  B.,  having  exposed  his  head  to  the  hot  sun  while 
bathing,  had  hemorrhage  into  both  retinee,  causing  com- 
plete blindness.  After  a  few  years,  he  fell  into  general 
paralysis  and  when  he  died,  the  author  found  that  the  optic 
nerves  were  hard  gray  cords,  with  no  nerv^e  substance  left, 
and  the  optic  tracts  in  the  same  condition.  The  gray  scle- 
rotic condition  could  be  traced  to  the  corpora  quadrigemina, 
the  posterior  of  which  were  gray  and  sclerotic.  (Abstract, 
Clouston,  op.  cit.^  p.  398.) 

THREE    CASES    OF    GENERAL    PARESIS    BEGINNING 
WITH    OPTIC    ATROPHY. 

Case  I.  In  a  man,  aged  37,  who  had  had  syphilis,  the 
first  symptom  of  illness  was  sudden  loss  of  vision.  The 
left  pupil  was  dilated  and  the  knee-jerk  absent.  Vision 
soon  returned,  but  the  pupil  remained  dilated.  There  was 
some  diplopia  and  central  vision  only  was  retained.  In 
four  or  five  months,  vision  failed  again,  this  time  com- 
pletely. Afterwards  he  developed  characteristic  symp- 
toms of  tabes  and  later  all  the  phenomena  of  general 
paralysis.  He  died  six  years  after  the  occurrence  of  the 
ocular  symptoms. 

Case  2.  A  man,  ast.  36,  first  noted  a  sensation  like  the 
pricking  of  needles  in  the  right  side  of  the  face  with  a 
sudden  clouding  over  of  the  eyes,  and  a  great  deal  of 
vertigo.  He  saw  black  spots  and  bright  flashes  before  his 
eyes.     There  was    a    peripheral  limitation  of    the  visual 


EYE    SYMPTOMS.  I4I 

field  for  form  and  a  more  marked  limitation  for  color. 
There  was  no  change  in  the  eye-grounds.  The  general 
health  was  good,  but  sight  finally  was  lost.  Symptoms  of 
general  paralysis  followed.  Death  occurred  nine  years 
after  the  beginning  of  the  ocular  symptoms. 

Case  3.  A  man,  ast.  45,  with  a  history  of  syphilis,  first 
noticed  blurring  when  he  tried  to  read,  worse  in  the  left 
eye.  Vision  failed  rapidly ;  in  six  months  he  could  not 
recognize  people.  On  examination,  the  upper  part  of  the 
field  was  apparently  cut  off  and  contracted.  The  discs 
were  bluish.  In  the  right  eye,  there  was  a  narrow  partial 
zone  and  some  little  pigmentar}"  change.  There  was 
some  cortical  opacity  of  the  right  lens.  About  the  time 
that  the  eyes  began  to  fail,  the  man  noticed  his  legs  were 
growing  weak  and  gradually  t3^pical  symptoms  of  general 
paralysis  appeared.  A  later  examination  showed  a  typical 
gray  atrophy  of  the  optic  nerve.  The  knee-jerk  was 
absent;  the  gait  tottering  rather  than  ataxic.  He  could 
stand  still  with  his  eyes  shut.  (Abstract,  Knapp,  Phila- 
delphia Medical  Journal,  Vol.  i,  p.  80.) 

GENERAL    PARESIS    WITH    OPTIC    NERVE 
ATROPHY. 

John  M.,  3et.  38,  admitted  with  general  paresis  and 
blind ;  an  ophthalmoscopic  examination  showed  well- 
marked  gray  atrophy  of  both  optic  discs,  but  the  vessels 
were  not  diminished  in  size.  (Abstract,  Wiglesworth, 
Journal  of  Mental  Science,  Vol.  35,  p.  389.) 

GENERAL    PARESIS    WITH    OPTIC    NERVE 
ATROPHY. 

A  woman,  £et.  26,  admitted  with  violent  mania  approach- 
ing the  acute  delirious  type  and  for  a  time  placed  her  in 
danger ;  no  reason  for  suspecting  general  paresis  till  an 
ophthalmoscopic  examination  disclosed  complete  white 
atrophy  of  the  optic  discs.  This  led  to  diagnosis  of  gen- 
eral paresis  which  subsequently  proved  correct.  (Abstract, 
Wiglesworth,  loc.  cz't.,  p.  390.) 


142  PARTICULAR    SYMPTOMATOLOGY. 

GENERAL    PARESIS    BEGINNING    WITH    CONGESTION    OF    THE 
OPTIC    DISCS. 

A  case  of  doubtful  diagnosis,  no  history  of  syphilis, 
decided  diminution  of  the  reflexes.  The  general  conges- 
tion of  the  optic  discs  led  to  an  ophthalmoscopic  examina- 
tion of  the  discs  with  the  result  that  they  were  found  to  be 
somewhat  blurred.  A  few  months  after  admission  he  showed 
marked  exalted  delusions  and  in  two  years  he  died.  During 
the  whole  course  of  the  disease,  he  had  congested  con- 
junctivae with  blurred  discs.  (Abstract,  Finegan,  Journal 
of  Mental  Science,  Vol.  55,  p.  620.) 

GENERAL    PARESIS    BEGINNING    WITH    CONGESTION    OF    THE 
OPTIC    DISCS. 

The  patient's  earliest  delusions  arose  from  failing  vision. 
He  thought  that  moss,  cobwebs,  nets,  etc.,  were  constantly 
falling  before  his  eyes.  Subsequently  he  became  suspi- 
cious and  said  that  the  oculist  had  put  out  his  eyes.  Later, 
other  organized  persecutory  delusions  appeared  and  led  to 
repeated  attempts  at  suicide.  There  was  a  distinct  history 
of  syphilis.  (Abstract,  Dawson  and  Rambaut,  Journal 
of  Mental  Science,  Vol.  55,  p.  621.) 


SYPHILIS,    PTOSIS,    EXTERNAL    STRABISMUS,    FOLLOWED 
BY    SYMPTOMS    OF    GENERAL    PARESIS. 

Walter  W.,  married;  agent;  uncle  insane.  He  had 
syphilis  long  ago.  He  has  recently  been  treated  for  ptosis 
and  external  strabismus,  and  recovered  entirely.  He  re- 
mained well  for  a  few  months  and  then  became  changed 
in  character ;  he  became  irritable  and  exacting  and  care- 
less in  business.  He  was  sleepless,  restless  and  extrava- 
gant a  month  before  admission.  On  admission,  he  was  a 
splendidly  built  man,  very  restless,  constantly  writing  let- 
ters ;  he  had  the  greatest  ideas  of  his  capacity ;  played 
the  piano  constantly  with  great  vigor;  he  was  irritable. 
Tongue  clear,  fairly  steady ;  pupils  unequal,  right  the 
larger ;  reflexes  deficient ;  writing  tremulous  ;  speech  hesi- 


EYE    SYMPTOMS.  1 43 

tant.  He  remained  in  a  restless  excited  state  for  nearly  a 
year,  when  he  gave  up  writing  and  became  weaker  in 
every  way.  Facial  and  lingual  tremors  became  more 
marked;  he  became  self-negligent  and  at  times  wet  and 
dirty.  His  memory  failed  and  he  is  rapidly  passing  into 
a  demented  state.     (Abstract,  Savage.) 

AN  INTERESTING  CASE  OF  GENERAL  PARESIS  PRECEDED 

BY  TYPICAL  ATAXY.   BECAME  BOTH  BLIND  AND 

DEAF  WITH  SYMPTOMS  OF  BULBAR  PARALYSIS. 

R.  M.,  married,  set.  47,  merchant,  no  insane  relatives, 
mother  died  asthmatic;  no  known  cause  for  the  illness. 
First  symptoms,  he  refused  to  see  people,  and  threatened 
to  drown  himself.  He  had  increasing  difficulty  in  express- 
ing his  ideas,  became  altered  in  manner,  and  his  memory 
failed ;  he  had  a  habit  of  letting  his  saliva  run  from  his 
mouth.  Before  admission,  he  became  reckless  in  business 
and  emotional,  especially  at  night,  when  he  would  bellow 
for  hours  together.  On  admission,  he  thought  everyone 
was  against  him,  refused  food,  had  exaltation  of  ideas, 
thickness  of  speech  and  ataxic  walk,  which  had  been  pres- 
ent over  a  year.  Two  months  after,  he  was  more  shaky 
on  his  legs,  and  optic  discs  were  partly  atrophied  ;  later,  he 
had  a  slight  attack  of  faintness,  followed  by  slight  loss  of 
power  in  left  thigh ;  patella  reflex  was  absent.  At  end  of 
a  year  both  discs  were  markedly  atrophic,  deafness  was 
noted.  Although  feeble,  he  was  restless.  In  the  latter  part 
of  this  year  he  had  a  fit  and  from  that  time  lost  power 
rapidly  ;  after  the  fit  he  was  unconscious  ;  tongue  dry  and 
brown,  pulse  74,  axillary  temperature  98° ;  surface  tem- 
perature of  forehead,  right  side,  93°.8,  left,  94°.6  ;  twitch- 
ing of  the  right  side  ;  inability  to  swallow  ;  left  pupil  large, 
both  pupils  insensible  to  light ;  the  patient  died.  (Abstract, 
Savage,  on  Insanity,  p.  317.) 

ILLUSTRATIVE    OF    CHANGES    IN    PUPILS. 

In  this  patient  the  pupils  are  unequal  during  some  portion 
of  every  day,  and  the  pupil  which  is  the  most  dilated  during 


144  PARTICULAR     SYMPTOMATOLOGY. 

the  morning  frequently  becomes  the  smallest  in  the  after- 
noon. Both  pupils  react  sluggishly  to  the  sunlight.  The 
edges  of  the  left  pupil  become  irregular  so  that  the  two 
sides  do  not  appear  exactly  alike  nor  conform  to  the  normal 
outline.  In  two  other  cases,  the  so-called  pinhole  pupil 
was  present  during  a  portion  of  the  pronounced  period, 
one  of  which  (cases)  at  the  same  time  experienced  periods 
of  great  excitement.     (Abstract,  Stearns,  o^.  cit.,  p.  496.) 


CHAPTER  XII. 

PARTICULAR    SYMPTOMATOLOGY    [continued). 

Sleep. — Insomnia  is  one  of  the  earliest  disturbances 
of  the  disease,  but  usually  it  is  not  looked  upon  with 
anxiety  by  the  patient.  Frequently  there  is  drowsi- 
ness through  the  day,  or  a  tendency  to  sleep  after 
eating.  The  nights  are  passed  in  much  sleepless- 
ness, or  the  sleep  is  light  and  not  invigorating,  troubled 
by  dreams,  or  nightmares  or  startings. 

In  some  cases  there  is  found  a  special  type  of  res- 
piration occurring  in  sleep.  It  is  carried  on  by  short 
inspirations  that  hardly  raise  the  chest  walls  and  there 
are  frequent  long  and  plaintive  expirations.  This  mode 
of  breathing  is  found  at  times  in  all  stages  of  the  disease. 

Pains. — The  patient  complains  very  frequentl}'  in 
the  prodromal  stage  of  sharp  pains  like  neuralgia,  or 
sharp  rheumatic  pains  in  the  limbs,  and  sometimes 
through  the  body.  Usually  they  are  not  localized, 
and  for  that  reason  seem  to  the  patient  the  more  un- 
accountable. At  times,  or  in  some  cases,  the  pain 
may  be  localized,  but  comes  and  goes,  causing  the 
most  intense  agony  for  the  time.  It  may  continue  as 
a  neuralgic  pain  in  the  head,  or  in  some  part  of  the 
body,  and  attacks  of  hyperesthesia  of  parts  sometimes 
cause  intense  suffering.  The  pains  are  described  as 
sharp,  lancinating,  or  flashing,  and  frequently  are  but 
momentary.  Occasionally  girdle  pains  are  com- 
plained of,  and  sometimes,  also,  an  intense  burning 
pain  over  a  certain  spot  on  the  knee  or  foot. 

These  pains  usually  disappear  as  the  disease  makes 
its  true  motive  apparent. 


146  PARTICULAR    SYMPTOMATOLOGY. 

Headache.  —  Among  the  prodromal  symptoms  is 
headache.  The  headache  is  sometimes  neuralgic  in 
character,  at  other  times  accompanied  by  tenderness, 
or  feeling  of  lightness  in  the  head  (Shaw). 

Severe  frontal  headache  is  present  in  almost  all 
cases  suffering  from  the  tabetic  form;  and  the  patient 
frequently  rubs  the  hair  from  the  frontal  region,  or 
from  one  entire  side  of  the  head  in  his  attempt  to  rid 
himself  of  the  constant  pain;  or  he  may  knock  his 
head  against  the  wall  in  his  desire  for  relief.  In  all 
forms  the  headache  disappears  as  the  disease  ad- 
vances. Precedent  migraine,  says  Mickle,  often  dis- 
appears at  the  development  of  general  paresis. 

Sensory  Disturbances.  —  Sooner  or  later  in  the  dis- 
ease, later,  according  to  Clouston,  there  is  loss  of 
special  sensations  and  impairment  of  the  cutaneous 
sensibilities.  The  latter  are  noticeable  in  very  defi- 
nite regions.  Macpherson  states,  "  As  a  rule,  they 
are  most  pronounced  in  the  following  order:  on  the 
chest  in  front,  in  the  lower  limbs,  the  upper  limbs, 
and  the  face  and  hands."  This  applies  both  to  ther- 
mal sense  and  the  loss  of  feeling  of  pain.  A  curious 
symptom  noted  by  Giannone  is  that  of  analgesia  of 
the  ulnar  nerve.  This  author  states  that  if  the  ulnar 
nerve  be  pressed  upon  as  it  passes  over  the  groove 
in  the  humerus,  the  arm  in  the  flexed  position,  it  will 
be  found,  pain  is  absent  in  53  per  cent,  of  the  cases 
and  diminished  in  25  per  cent. 

In  addition  to  the  anesthesia  of  the  skin,  loss  of 
special  senses  occurs.  That  of  the  eye  has  already 
been  considered  in  detail.  Deafness,  aphonia,  loss 
of  control  of  the  muscles  of  deglutition,  are  all  fre- 
quent sensory  disturbances.  Not  infrequently  the 
patient  may  strangle  from  a  bolus  of  food,  or  a  stom- 
ach tube  may  reach  the  trachea  or  bronchi  without 
any  sign  on  the  part  of  the  patient.     The  sense  of 


SENSORY    DISTURBANCES.  I47 

taste  may  become  so  deranged  that  the  patient  can- 
not distinguish  between  substances  placed  in  the 
mouth;  and  the  olfactory  sense,  also,  may  be  so 
deficient  that  no  odor  however  bad  gives  annoyance, 
or  is  noticed  by  him.  This  loss  of  sensation  is  pro- 
gressive, and  is  believed  by  Clouston  to  be  due  to 
primary  degeneration  in  the  cortical  centers  of  spe- 
cial sense  and  their  terminal  nerve  apparatus.  As 
already  noted  under  the  ocular  symptoms,  visual  im- 
perfections, color-blindness,  or  visual  hyperesthesia 
may  be  present. 

TWO    CASES    OF    GENERAL    PARESIS    IN    WHICH    THERE    WAS 
BLOOD    SWEATING. 

Severes  describes  two  cases  of  general  paresis  in  the 
latter  stages  of  which  blood  sweating  about  the  face  was 
observed.  They  were  cases  of  long  standing,  in  which 
the  power  of  articulation  was  almost  lost  and  muscular 
paralysis  complete.  There  was  observed  a  great  multitude 
of  coagulated  blood  drops  about  the  face.  After  being 
wiped  away,  other  drops  appeared  in  about  two  hours, 
appearing  as  though  the  face  had  been  picked  all  over 
with  a  fine  needle.  At  the  same  time,  the  temperature 
of  the  head  was  increased,  pulse  120  and  weak.  After 
two  days  this  curious  symptom  disappeared,  leaving  rose- 
colored  spots  where  the  sweating  had  been  most  extensive. 
(Abstract,  American  Journal  of  Insanity,  Vol.  20,  p.  356.) 

GENERAL    PARESIS    WITH    SENSORY    PERVERSIONS. 

A  patient  believed  that  his  skin  was  tucked  in,  another 
that  it  was  hung  up  to  dry,  another  was  continually  pick- 
ing off  "  gold  leaf "  from  his  bodily  surface.  (Abstract, 
Spitzka,  on  Insanity,  p.  202.) 

A    CASE    OF    GENERAL    PARESIS    IN   WHICH   THE    KINES- 
THETIC   SENSE    WAS    LOST. 

A  patient  had  conducted  a  large  business  and  had 
accumulated    considerable    property.     Yet    after    his  ad- 


«  V 


148  PARTICULAR     SYMPTOMATOLOGY. 

mission,  he  never  referred  to  the  past  or  inquired  for  his 
friends.  When  his  relatives  called  to  see  him,  he  replied 
to  their  inquiries  at  times  correctly  and  at  others  incorrectly. 
He  never  expressed  pleasure  or  displeasure  at  their  visits 
or  requested  them  to  come  again.  He  never  wrote  or 
took  interest  in  letters  written  to  him.  He  was  accustomed 
to  spend  the  time  looking  out  of  the  window,  or  walking 
up  and  down  the  hall.  Two  or  three  months  after  ad- 
mission, he  lost  his  personal  identity  and  insisted  that  he 
should  be  called  Johnson.  After  a  residence  of  sixteen 
months,  during  which  he  never  expressed  a  regret  or 
pleasure,  he  had  an  epileptiform  seizure  from  the  effect 
of  which  he  did  not  recover.  This  case  was  unusual  in 
the  almost  total  absence  of  emotional  expression  or  desire. 
(Abstract,  Stearns,  Mental  Diseases,  p.  488.) 

A    CASE    OF    PARESIS    WITH     MARKED    SENSORY     SYMPTOMS. 

In  this  case,  affection  of  sight  from  optic  atrophy  was 
among  the  earliest  symptoms  of  the  disease.  Three 
months  before  admission  the  patient  had  consulted  Dr. 
Swanzy  at  the  National  Eye  and  Ear  Infirmary  who  found 
optic  atrophy,  also  Argyll-Robertson  pupil  and  at  times 
slight  affection  of  speech  and  he  diagnosed  general  par- 
alysis. The  ocular  lesions  determined  the  form  of  the 
delusions.  In  the  earlier  stages  he  saw  spiders,  white 
skeletons,  moving  objects,  crabs  and  different  colored 
mosses,  later  he  complained  of  fluff,  flies  and  worms  being 
thrown  into  his  eyes  and  then  of  buildings  being  erected 
at  the  back  of  his  eyes,  which  blocked  out  his  vision.  He 
was  depressed  and  suspicious.  There  was  no  history  of 
syphilis  or  alcoholism.  (Abstract,  Dawson  &  Rambaut, 
Journal  of  Mental  Science,  Vol.  45,  p.  620.) 

A    CASE    OF    GENERAL    PARESIS    WITH    MARKED 
SENSORY    SYMPTOMS. 

P.  T.,  ast.  36,  army  pensioner.  History  of  syphilis  and 
sexual  excess  ;  he  has  two  health}'  children.  Two  years 
ago  the  patient  began  to  suffer  with  convulsions,  treated  as 
idiopathic  epilepsy.      He  was  admitted  in  February,  then  he 


TROPHIC    CHANGES.  I49 

had  slight  tongue  tremor  and  flattening  of  face,  articulatory 
slurring,  and  very  exaggerated  patellar  reflex ;  pupillary 
reactions  and  fundus  oculi  were  normal,  also  common  and 
special  sensibility.  He  had  mild  exaltation  but  no  delusion. 
There  was  no  change  till  April,  when  he  had  several  attacks 
of  petit  mal,  preceded  by  darting  pains  in  the  legs,  and  fol- 
lowed by  a  temporary  accentuation  of  the  physical  signs. 
With  the  onset  of  these  attacks  optimism  disappeared  and 
he  had  persecutory  ideas,  attributing  his  sufferings  to 
drugs  in  his  food,  etc.  When  the  attack  passed  ofi  the 
exaltation  returned  and  it  was  more  marked ;  God  had 
touched  and  cured  him,  etc.  In  May,  a  more  severe  con- 
gestive attack  was  succeeded  by  temporary  aphasia  and 
right  brachial  paresis,  the  mental  state  being  depressed. 
A  remission  of  mental  and  physical  symptoms  followed 
this  until  September,  when  another  similar  attack  occurred, 
with  no  sensory  disturbances  except  the  darting  pains  at 
the  outset.  Near  the  end  of  November,  he  had  a  severe 
congestive  seizure,  preceded  by  intense  darting  pains  and 
leaving  a  condition  of  left  hemiparesis,  also  a  mental  state 
of  panic  terror ;  he  seized  the  paretic  arm  with  the  sound 
hand  and  shrieked,  "  Take  it  away,  the  big  serpent  is  bit- 
ing me."  Furor  was  too  great  to  allow  observation  of  sen- 
sory condition.  This  excitement  subsided  after  some  hours 
and  the  paretic  symptoms  passed  off,  leaving  patient  ver}^ 
dull  and  confused ;  he  said  a  big  serpent  had  bitten  him  on 
left  side,  but  God  had  saved  him  because  of  his  holiness. 
Sensibility  to  pain  and  touch  were  not  lessened  on  left 
side.  On  December  9th  there  was  a  revival  of  the  furor 
with  the  former  delusion,  but  without  motor  paralysis. 
On  December  25th  another  congestive  attack  was  fol- 
lowed by  left  hemiplegia  and  hemianesthesia  ;  patient  was 
happy,  fondled  affected  arm,  calling  it  the  little  son  that 
God  had  brought  to  him.  In  a  day  or  two  localized  motor 
and  sensory  paralysis  passed  off,  but  dementia  became 
profound.  The  patient  died  of  cardiac  paralysis  in  January 
following.     (Abstract,  Sullivan,  W.  C.) 

Trophic  Changes. — One  of  the  most  interesting  con- 
ditions, prevailing  in  the  later  stage  of  the  disease, 
13 


150  PARTICULAR     SYMPTOMATOLOGY. 

is  the  trophic  changes.  These  are  numerous  and 
varied,  and  for  the  most  part  are  real  trophoneuroses. 
For  instance  the  tendency  to  sacral  decubitus  is  due 
not  to  the  wet  habit  alone,  but  to  a  certain  degree  of 
trophic  trouble  which  is  always  present. 

Other  changes  to  be  expected  at  times  are  the  loss 
ot  teeth  and  nails,  the  latter  becoming  extremely 
brittle  and  fissured.  The  hair  likewise  sufiers:  it 
gets  dark,  brittle,  and  scant  and  occasionally  it  be- 
comes almost  white.  The  knees,  elbows,  and  other 
points  of  the  body,  are  prone  to  ulceration,  even 
though  there  be  but  the  weight  of  very  light  bed- 
clothing,  such  as  a  sheet.  These  regions,  as  well 
as  large  areas  of  the  skin,  occasionally  break  down 
and  slough,  from  no  other  cause  than  trophic  alter- 
ation. Abscesses,  erythematous  eruptions,  perforat- 
ing ulcers  of  the  foot,  have  been  described,  due  to 
the  same  cause. 

Progressive  muscular  atrophy  is  not  uncommon. 
This  may  take  the  pseudo-hypertrophic  form  and  the 
muscles  seem  to  increase  in  size,  because  of  the  latty 
infiltration  and  subsequent  deposit  (with  wasting)  of 
fibrous  tissue. 

The  bones  likewise  suffer,  becoming  infiltrated  with 
fat,  which  is  deposited  in  the  Haversian  canals. 
This  is  associated  with  progressive  increase  in  the 
amount  of  organic  and  a  consequent  decrease  in  the 
amount  of  inorganic  material.  This  process  may  go 
on  to  such  an  extent  that  the  bones  become  very 
brittle,  a  condition  closely  approaching  osteomalacia, 
and  fracture  of  them  is  then  a  very  simple  matter. 
Trophic  changes  in  the  joints,  as  well  as  of  the  bones, 
occur  at  times.  These  arthropathies  are  similar  to 
those  found  in  locomotor  ataxia  and  like  them  are 
found  in  cases  of  the  "ascending  type"  of  paresis, 
in  which  the  spinal  precede  the  cerebral  symptoms. 


TROPHIC    CHANGES. 


151 


Fig.  2. 


and  so  doubtless  depend  upon  lesions  of  the  spinal 
cord.  An  interesting  case,  involving  both  hip  joints, 
was  seen  recently  at  the  Philadelphia  Hospital  in  a 
paretic.  The  sternum  and  ribs  may  become  firmly 
united  by  reason  of  ossification  of  the  cartilages. 
The  thorax  thereby  becomes  a  rigid  case,  and  breath- 
ing is  only  successfully  accomplished  by  bringing  into 
use  the  accessory  muscles  of  res- 
piration. Macpherson  calls  atten- 
tion to  the  fact  that  incurving  with 
elongation  and  ossification  of  the 
xyphoid  portion  of  the  sternum  is 
quite  apt  to  cause  much  pain  and 
annoyance  to'the  patient  in  breath- 
ing. 

Among  other  trophic  changes 
may  be  noted  the  absence  of  the 
general  health}^  appearance  of  the 
skin.  A  diminution  of  the  hem- 
oglobin, giving  a  color  index  vary- 
ing from  0.5  to  .85  of  the  normal 
and  a  lower  number  of  red  cor- 
puscles, are  constantly  to  be  ob- 
served. Herpes  zoster  and  furun- 
culosis,  faintly  indicated  at  first, 
may  become  so  serious  as  to  en- 
danger the  life  of  the  patient. 
Hematoma  of  lower  bowel,  diarrhea  and 
hemorrhage  may  supervene.  Hematoma  of  the  ear, 
another  trophic  change,  is  treated  under  separate  head. 


Arthropathy  of  Knee 

Joint.     {A.  S.  Roberts, 
vide  Dana.) 


gastric 


GENERAL   PARESIS   WITH    ARTHROPATHY    OF    KNEE  JOINTS. 

J.  D.,  ^t.  38  ;  white,  admitted  in  July.  He  had  suffered 
for  some  years  with  pain  in  the  legs,  which  had  been 
called  rheumatic.  Otherwise  he  was  healthy  up  to  a  year 
and  a  half  before  admission  when  he  had  a  swelling  of 


152  PARTICULAR     SYMPTOMATOLOGY. 

the  knees.  Six  months  before  admission,  he  began  to 
have  persecutory  delusions  ;  he  became  silly  and  weak. 
Drawling  speech  began  three  months  before  admission. 
There  had  been  no  convulsions,  or  history  of  syphilis. 
On  admission  he  was  very  demented.  Both  knee  joints 
were  enormously  enlarged  ;  grating  sounds  could  be  heard 
in  them  easily.  The  anterior  end  of  the  condyles  of  the 
femur  was  enlarged.  Shorth^  after  admission,  he  had  a 
maniacal  episode.  After  this,  he  showed  a  grandiose  delu- 
sional state  ;  he  was  more  demented  ;  he  talked  incoherently 
about  finding  immense  sums  of  money.  His  speech  be- 
came more  drawling  and  unsteady.  He  managed  to  walk 
about,  but  the  joints  grew  more  deformed.  The  patellar 
were  flattened,  disfigured,  and  increased  in  diameter ;  the 
bosses  on  the  condyles  were  ver}'  prominent ;  no  stalactites 
could  be  determined ;  grating  sounds  could  always  be 
heard  ;  the  joints  were  painless  and  free  from  heat  or  red- 
ness;  there  was  increase  of  fluid  within  them;  no  edema 
about  them  but  the  skin  felt  hard  and  tough ;  there  was 
increased  lateral  movement.  Very  strong  electrical  cur- 
rents failed  to  cause  contractions  in  the  muscles  of  the 
thighs  and  legs,  except  in  the  peroneal  group  of  the  right 
leg.      He  died  of  edema  of  the  lungs. 

The  post-mortem  findings  of  the  knee  joints  are  given. 
The  right  joint  was  as  follows  :  The  synovic  membrane 
in  front  was  of  a  steel-gray  color,  mottled  with  blue 
patches  and  covered  with  numerous  small  miliary  calcare- 
ous nodules.  The  anterior  edges  of  the  cond3'les  of  the 
femur  were  greatly  hypertrophied  in  nodular  masses  or 
rugosities.  These  formed  bosses  extending  upwards  and 
outwards  about  two  centimeters  beyond  the  edge  of  the 
condyle.  In  the  anterior  notch  between  the  condyles  was 
a  triangular  mass  of  nodules  embedded  in  tissue  and  freely 
movable.  These  nodules  were  of  stony  hardness.  Over 
the  articular  surface  of  the  right  condyle  there  was  left  the 
lining  membrane  of  the  joint  considerably  thickened  and 
rough  in  some  places,  in  others  thin,  and  presenting  about 
the  center  an  eroded  patch.  Over  the  surface  of  the  left 
condyle,  the  lining  membrane  was  absent,  and  the  bone 


TROPHIC    CHANGES.  1 53 

was  worn  and  eroded,  especially  toward  the  periphery. 
There  was  a  series  of  small  eroded  patches  with  nodules 
running  along  the  outer  border  to  the  posterior  extremity 
of  the  condyle.  In  brief,  most  of  the  soft  structures  of  the 
joint  showed  destructive  changes.  The  semilunar  carti- 
lages were  much  worn  and  eroded,  and  easily  displaced. 
The  inner  surface  of  the  capsular  ligament  showed  some 
pedunculated  masses.  The  crucial  ligaments  were  appar- 
ently wasted,  but  still  held  firmly.  The  end  of  the  tibia 
was  covered  with  thin,  worn  and  eroded  membrane  ;  part 
of  the  surface  of  the  bone  was  bare.  The  joint  contained 
a  green,  thick,  opaque  fluid.  The  patella  was  quite  de- 
formed. It  was  thin  and  flattened,  with  rugous  edges. 
The  under  surface  was  covered  with  shreds  of  membrane. 
The  capsular  ligament  was  much  distended  and  the  joint 
cavity  extended  to  an  abnormal  limit  upon  the  front  of  the 
femur.  The  left  knee  joint  was  rather  larger  and  more 
distended  than  the  right.  The  same  general  characteristics 
were  to  be  noted — distended  capsule,  eroded  membranes, 
nodular  pedunculated  formations,  and  bony  bosses  on  the 
anterior  edges  of  the  condyles.  (Abstract,  Lloyd,  J.  H., 
Journal  of  Nervous  and  Mental  Diseases,  Vol.  i8,  p.  83.) 

A     CASE     OF     GENERAL     PARESIS     SUPERVENING    ON    TABES 
DORSALIS,    MARKED    TROPHIC    DISTURBANCES. 

C,  ast.  37,  male,  married  for  six  years,  one  child,  five 
years  old ;  phthisis  on  both  sides  of  the  family  ;  his  father 
had  died  of  diabetes,  his  brothers  were  intemperate.  He 
had  been  a  medical  student,  drifting  on  for  years  without 
obtaining  a  qualification  and  had  led  a  fast  life.  He  was  sus- 
pected of  syphilis  but  denies  it ;  of  late  he  has  been  temper- 
ate. Six  years  ago  he  received  a  blow  on  the  head  and  neck 
and  since  then  has  been  a  changed  man.  Soon  after  he  got 
married,  sexual  vigor  much  diminished.  His  marriage 
involved  him  in  pecuniary  worry,  to  which  he  was  unac- 
customed ;  felt  depressed;  lightning  pains  in  the  limbs; 
six  to  eight  weeks  before  admission,  seized  with  agonizing 
pains  down  his  back.  Similar  attack  affecting  head  a 
week  later.     A  year  ago  he  had  become  captious,  irritable 


154  PARTICULAR     SYMPTOMATOLOGY. 

and  unlike  himself;  more  recently  he  had  been  depressed, 
hysterical  and  high  spirited  by  turns  and  occasionally  vio- 
lent. Exaltation  appeared  a  month  before  admission.  On 
admission,  June  i8,  he  was  anemic  and  cachectic ;  pupils 
contracted  and  sluggish,  the  left  slightly  ;  the  larger  patel- 
lar reflexes  absent ;  with  feet  together  and  eyes  shut,  a 
little  disposition  to  totter ;  pains  down  his  legs,  which  he 
said  had  lasted  on  and  off  since  his  accident  six  years  ago, 
also  a  sense  of  abdominal  constriction  of  recent  origin. 
Said  he  was  passing  water  with  a  less  forcible  stream  and 
that  there  was  dullness  of  sensation  on  both  ulnar  regions, 
but  no  anesthesia  was  detected  on  testing.  His  com- 
plaints too,  as  to  defective  eyesight  seemed  unfounded. 
No  heat,  pain  or  tenderness  over  scalp  or  spine.  Articu- 
lation distinct,  skin  greasy.  Temperature  normal,  urine 
neutral,  sleep  and  appetite  good.  He  was  exalted  and  jolly  ; 
said  he  would  do  great  good  to  the  patients  around  him 
almost  involuntarily,  by  the  magnetic  power  which  he  felt 
permeating  his  whole  system  ;  said  he  had  made  his  fortune 
in  a  day,  that  he  was  going  to  stand  for  Parliament,  etc.  ; 
his  handwriting  was  unintelligible,  due  to  misspellings, 
omitted  words,  etc.  ;  memory  was  so  bad  that  he  misstated 
his  age  by  ten  years.  He  was  clean,  stuck  a  feather  in 
his  hat  and  fraternized  with  the  most  demented  patients  and 
was  fanciful  and  hysterical.  The  case  seemed  to  be  one 
of  general  paresis  supervening  on  tabes  dorsalis.  For  first 
twenty-four  hours  he  spoke  only  in  a  whisper,  but  the  un- 
interrupted current  applied  to  the  outside  of  the  larynx, 
restored  his  full  voice,  to  his  great  delight.  General  health 
improved,  but  he  lost  physical  power.  There  were  many 
grandiose  delusions  and  much  emotional  instabilit}-.  After 
eight  months,  he  complained  greatly  of  weakness  and  often 
fell  down  in  dancing.  Twelve  months  from  admission  he 
had  two  slight  convulsive  seizures,  chiefly  affecting  the  right 
side,  followed  in  two  weeks  by  frantic,  destructive  mania. 
Physical  degeneration  set  in,  catheter  often  needed  ;  he  had 
albuminuria.  Cellulitis  appeared  in  both  feet  and  spread, 
on  which  treatment  made  no  impression.  In  a  short  time, 
the  muscles  of  the  legs  were  almost  in  ribbons  and  every 


TROPHIC    CHANGES.  155 

part  of  his  body  exposed  to  pressure  assumed  an  inflamma- 
tory tint  which  deepened  rapidly  into  a  slough.  The 
mania  left  great  exhaustion,  unaffected  by  stimulants. 
His  physical  condition  hourly  degenerated  and  no  one 
thought  he  could  live  another  day.  His  friends,  not  wish- 
ing him  to  die  in  an  asylum,  had  him  removed  in  a  carriage, 
one  mass  of  mortifying  corruption.  From  that  time  he 
began  to  mend  and  was  soon  well  in  body  but  somewhat 
silly  in  mind.  (Extract,  Fox,  B.  B.,  Journal  of  Mental 
Science,  Vol.  37,  p.  394.) 

GANGRENE    OF    THE    LIP    IN    A    PARETIC,  FROM    SUCTION. 

A  man  in  the  last  stage  of  general  paresis  was  discovered 
holding  his  lower  lip  firmly  between  his  teeth ;  he  had  not 
held  it  there  over  four  and  a  half  hours.  The  lip  was 
swollen,  discolored  and  black  in  places.  The  greater  part 
of  the  lip  sloughed  away ;  the  wound  healing  without  diffi- 
culty.    (Abstract,  Arch,  de  Neurol.,  Sept.,  1892.) 

A    CASE    OF    GENERAL    PARESIS    IN    WHICH    MARKED    IM- 
PROVEMENT   OCCURRED    AFTER    EXTENSIVE 
SLOUGHS. 

Male,  set.  37  ;  lawyer  ;  no  insane  heredity  ;  no  history  of 
syphilis.  He  used  tobacco  excessively  and  had  been  licen- 
tious ;  disposition  genial ;  temperament  sanguine.  He  was 
an  able  attorney  and  was  moderately  successful  financially. 
On  admission,  he  had  been  breaking  down  for  a  year,  but 
had  made  a  show  of  practicing  his  profession  up  to  within  a 
few  weeks.  He  first  showed  inordinate  sexual  desire  and 
extravagant  delusions.  Shortly  before  admission,  he  be- 
came violent.  He  believed  he  could  make  gold  and  dia- 
monds and  that  he  had  been  commanded  to  "  raise  Jesus 
and  to  be  a  Joseph."  On  admission,  he  was  anemic  and 
untidy ;  temperature  was  normal ;  pulse  96,  small,  irregu- 
lar and  feeble ;  bodily  health  apparently  reduced,  though 
he  was  as  well  as  for  several  months  before ;  pupils 
equal  and  contracted ;  speech  drawling  and  thick ;  gait 
ataxic.  He  entertained  impracticable  business  schemes 
of  great  magnitude.     His  manner  was  dull  and  preoccu- 


156  PARTICULAR     SYMPTOMATOLOGY. 

pied  and  his  expression  indicated  mental  impairment.  He 
remained  bewildered  several  days  after  admission  ;  he  was 
inclined  to  lie  down,  pound  on  doors,  injure  furniture  and 
remove  his  clothes.  A  few  weeks  after  admission,  July 
24,  he  is  still  restless.  August  4,  he  is  less  confused  and 
quieter,  and  has  a  ravenous  appetite.  He  says  he  has  a 
great  invention  for  tubular  locomotion,  consisting  of  two 
glass  balls.  One  ball  is  fastened  to  a  pole  ;  the  other  is 
"  a  solid  globe,  with  the  exception  of  four  little  holes  for 
the  admission  of  air  and  water  where  the  friction  occurs." 
The  "capacity"  of  this  apparatus  is  one  thousand  miles  a 
minute.  His  conversation  is  incoherent  and  he  speaks  of 
going  "to  the  end  of  the  universe  at  the  end  of  a  spark." 
During  the  passage  of  the  electrical  current  through  the 
negative  pole  in  the  auriculo-maxillary  fossa  to  the  ver- 
tex, he  complained  of  haziness  of  vision,  as  though  he 
were  looking  through  steam.  After  two  electrizations, 
his  pupils  were  a  trifle  larger,  and  his  skin  cooler. 
August  15,  tendon  reflex  cannot  be  obtained  owing  to 
muscular  rigidity ;  tongue  deviates  to  the  right  and  is 
coated ;  pulse  90  and  somewhat  feeble ;  skin  cool  and 
pupils  contracted  ;  temperature  98'^.5  ;  mental  action  more 
feeble  ;  he  cannot  follow  the  simplest  directions.  August 
27,  he  has  steadily  lost  ground;  very  noisy  and  mis- 
chievous and  greatly  disturbed  at  night.  September, 
he  is  prone  to  remove  all  his  clothing ;  believes  he  is 
Jesus  Christ;  no  decline  in  bodily  health.  October  i,  he 
has  had  retention  of  urine  recently.  On  the  second  he 
had  a  mild  paretic  attack.  He  became  pale,  weak,  and 
momentarily  unconscious.  On  the  third  he  had  an  in- 
flamed testicle ;  he  took  food  poorly  and  was  feeble. 
Fifth,  cystitis  developed ;  much  muco-pus  in  the  urine. 
Seventh,  he  is  very  low  and  does  not  take  food  well ; 
pulse  weak  and  rapid  ;  he  passes  all  his  urine  in  bed  and  is 
in  a  wretched  condition.  Tenth,  he  is  much  better  and 
takes  food  well.  The  orchitis  is  subsiding,  no  abdominal 
tenderness ;  says  he  is  in  perfect  health  and  is  taking 
solid  food.  Fourteenth,  his  urine  is  intensely  alkaline, 
contains  pus   and  is  of  a  horrible  odor.     From    the   six- 


TROPHIC    CHANGES.  157 

teenth  to  the  twenty-first  he  was  in  a  highly  critical  condi- 
tion. An  abscess  formed  in  the  right  side  of  the  scrotum ; 
there  was  constant  dribbling  of  urine ;  genitals  and  thighs 
were  excoriated.  Twenty-fourth,  there  is  a  constant  dis- 
charge of  pus  and  induration  of  the  testicle ;  dribbling  of 
urine  continues  ;  he  has  a  bed-sore  over  the  sacrum  which 
developed  very  rapidly.  Until  November,  he  seemed  to 
have  acute  pain  in  the  back,  although  he  said  he  felt  none  ; 
he  took  very  little  solid  food  and  required  constant  atten- 
tion ;  his  bed-sore  became  very  large  and  he  constantly  lost 
ground  physically.  November  i,  he  requires  the  utmost 
personal  attention  and  is  slowly  failing.  The  bed-sore  is 
becoming  deeper.  Death  at  an  early  date  is  apprehended. 
Fifth,  the  destructive  crisis  has  been  arrested.  The  slough 
has  separated,  except  in  the  center.  A  portion  shows 
suppurative  action.  Eighteenth,  bed-sore  better ;  general 
health  improved  but  not  his  personal  habits.  January 
following :  He  is  more  quiet  and  less  irritable  ;  appetite 
good ;  is  gaining  flesh ;  bed-sore  no  larger  than  a  silver 
dollar ;  he  is  able  to  sit  up  and  take  his  meals  in  the  dining 
room  ;  gait  feeble.  Thirtieth,  he  reads  much  and  is  glad 
to  be  out  of  bed.  April  3,  he  steadily  improves  ;  quiet,  or- 
derly, and  usually  pleasant ;  he  does  not  appreciate  his 
past  or  present  mental  condition  and  often  asks  to  be  ex- 
amined and  sent  home ;  he  has  no  extravagant  delusions ; 
he  addresses  an  envelope  in  a  business-like  style.  May 
18,  he  sits  quietly  in  a  room  by  himself ;  he  is  given  to  ges- 
ticulating. Nineteenth,  he  converses  coherently ;  his 
statements  are  plausible ;  no  difficulty  in  articulation ;  he 
can  stand  erect  with  his  eyes  shut  and  shows  little  ataxia ; 
he  executes  fine  movements  with  considerable  precision. 
June  3,  removed  from  the  hospital  on  trial.  March  of 
the  next  year,  he  has  tried  to  practice  law,  but  could  not 
accomplish  much.  He  w^as  reported  as  having  seemed 
"out  of  balance."  He  has  made  himself  a  great  annoy- 
ance in  the  courts  by  issuing  fictitious  papers  and  institut- 
ing law  suits  against  one  person  and  another.  He  also 
insisted  upon  his  right  to  address  the  court  in  season  and 
out  of  season.     On  his  return,  he  was  irritable  and  spoke 

14 


158  PARTICULAR     SYMPTOMATOLOGY. 

to  no  one.  He  remained  for  about  a  fortnight  moody  and 
preoccupied,  talking  little  and  taking  a  very  small  quan- 
tity of  food."  ]Vl^y  21,  he  converses  but  little  but  scolds 
the  superintendent  for  his  detention,  and  uses  profane 
language.  He  sits  alone  with  bowed  head  and  does  not 
speak.  November  8,  he  is  at  times  menacing  and  threaten- 
ing ;  he  spends  much  time  in  writing  and  is  cross  when 
asked  to  exhibit  his  manuscript.  December  14,  a  table 
knife  is  found  on  his  person.  He  replies  evasively  when 
questioned  as  to  what  he  purposed  doing  with  it.  March 
following,  his  bodily  health  is  as  good  as  at  any  time  since 
his  return.  He  is  pleasant  unless  annoyed  but  denounces 
the  officers  for  his  detention.  His  clumsiness  of  articula- 
tion may  be  natural  and  it  is  not  thick  and  indistinct.  He 
shows  no  incoordination  of  muscular  movement  and  takes 
long  walks  daily ;  he  will  not  let  the  physician  examine 
him  ;  pulse  98  ;  he  can  walk  backwards  and  forward  with 
closed  eyes,  and  does  it  easily.  His  printing  and  writing 
are  distinct.  (Abstract,  Burr,  C.  B.,  American  Journal 
of  Neurology  and  Psychology,  1884.) 

Bones.  —  Fractures  of  bones  are  found  more  fre- 
quently in  general  paresis  than  in  any  other  form  of 
insanity.  The  long  bones,  as  well  as  the  ribs,  some- 
times become  very  brittle,  due  to  the  absorption  of 
the  organic  constituents;  while  the  impairment  of 
nerve  force  leaves  the  patient  deprived  of  the  reflex 
guard  to  protect  him  from  danger.  Lacking  judg- 
ment to  protect  himself,  he  is  usually  liable  to  serious 
accidents  of  this  nature.  Not  only  is  there  delayed 
reaction,  in  dulled  reflex  movement,  but  frequently 
an  absence  of  sensitiveness  to  pain,  so  that  severe 
fractures  may  occur  without  a  sign  of  suffering. 
Again,  spontaneous  fractures  have  been  known;  but 
not  infrequently  do  the  fractures  of  paretics  unite 
naturally,  and  bed-sores  and  abscesses  heal  rapidly. 

Clouston,  in  accounting  for  the  fact  that  the  largest 
number  of  rib  fractures  in  asylum  practice  is  in  cases 


Plate  IXb. 


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1 

SPONTANEOUS  FRACTURES  AND  ARTHROPATHIC  DISINTEGRATIONS. 
(Charcot  per  Church-Peterson.) 


BONES.  159 

of  paresis,  states  that,  when  the  chest  is  struck,  or 
the  weight  of  another  patient  or  of  an  attendant  is 
thrown  on  it,  the  laryngeal  muscles  do  not  act  in  time 
to  close  the  lungs  and  make  them  resistive,  by  being 
filled  with  air  that  cannot  be  driven  out.  He  gives 
an  instance  of  a  patient  admitted  with  nine  ribs 
broken  on  one  side  and  four  on  the  other,  and  in 
spite  of  such  injury  he  shouted,  fought  and  rushed 
about  wildly,  regardless  of  an3lhing  like  inconveni- 
ence, and  with  an  absence  of  ordinary  feeling,  show- 
ing clearly  a  condition  of  dulness  of  sensation;  and 
concludes  that  this  very  dulness  of  sensibility  is  at 
the  foundation  of  these  fractures. 

It  is  in  the  second  stage,  when  the  patient  is  free 
and  unprotected,  that  accidents  and  resulting  frac- 
tures often  occur.  Sankey  says  that  too  frequently 
fractures  are  explained  to  the  detriment  of  the  at- 
tendant, and  advises  asylum  physicians  to  be  espe- 
cially watchful  for  this  complication  in  the  examina- 
tion for  admission.  He  adds  the  case  of  "  Leather- 
Coated  Jack,"  who,  reinforcing  his  ribs  by  the 
erection  of  the  intercostal  muscles,  would  allow  a 
cart  to  be  driven  over  his  chest,  and  shows  that  a 
general  paretic  has  no  such  forethought,  and  even  if 
he  had,  the  reflex  movements  would  be  too  slow  in 
their  action  to  be  of  avail. 

A    CASE    OF    GENERAL    PARESIS    IN    WHICH    MUSCULAR 
ACTION    CAUSED    FRACTURE    OF    LEG. 

A  male  with  general  paresis,  set.  42,  in  asylum  for  over 
two  years  ;  paresis  due  to  specific  disease,  and  he  had  been 
out  of  health  for  two  years  before  admission.  Ataxia  was 
a  prominent  feature ;  gait  clumsy  and  uncertain ;  pupils 
sluggish,  tendon  reflex  absent ;  he  was  extremely  appre- 
hensive with  extravagant  delusions  ;  mental  excitement  of 
a  furious  and  purposeless  character.  Afterwards  he  was 
in  a  quiescent  stage  when  one  day,  while  out  walking,  he 


l6o  PARTICULAR     SYMPTOMATOLOGY. 

attempted  to  turn  and  fell  and  broke  the  tibia  and  fibula  in 
the  lower  third  of  his  leg.  The  fracture  united  promptly 
and  convalescence  went  on  uninterruptedly.  (Abstract, 
Burr,  C.  B.,  American  Journal  of  Insanity,  Vol.  46,  p.  75.) 

A    CASE    OF    GENERAL    PARESIS    IN    WHICH    MUSCULAR 
ACTION    CAUSED    FRACTURE    OF    LEG. 

A  female,  ast.  34.  The  patient  had  been  suffering  in 
mind  five  months  before  admission.  She  had  a  paretic 
seizure  six  weeks  after  admission.  She  was  noticed  to  be 
ataxic,  and  had  difficulty  m  rising  from  her  chair.  The 
pain  and  ataxia  in  the  legs  were  soon  followed  by  incoordi- 
nation in  the  movements  of  the  arms  ;  she  had  difficulty  in 
feeding  herself ;  she  had  frequent  severe  headaches  and 
muscular  incoordination  was  not  noticeable  at  these  times. 
In  the  following  month  she  was  more  confused  and  de- 
structive of  clothing  ;  ataxia  increased  and  mental  powers 
rapidly  failed.  In  the  February  following  admission,  she 
showed  inequality  of  pupils,  and  then  had  a  second  paretic 
seizure,  with  difficulty  of  respiration,  high  temperature  and 
choreiform  movements.  On  April  17th  she  had  a  severe 
fall  in  turning  quickly  and  could  not  rise  ;  she  had  frac- 
tured right  femur  in  lower  third ;  no  evidence  of  any  con- 
tusion of  the  soft  parts  and  it  was  thought  that  the  turning 
and  not  the  fall  had  produced  the  fracture.  She  appeared 
to  have  no  pain  and  never  complained  during  the  dressing 
of  the  fracture.  In  fourteen  days  dressing  was  renewed, 
the  limb  was  in  excellent  position  and  showed  no  shorten- 
ing ;  there  was  much  callus.  Forty-one  days  after  injury 
she  could  lift  her  leg  easily  and  unconsciously.  (Abstract, 
Burr,  C.  B.,  loc.  cit.,  p.  73.) 

A    CASE    OF    GENERAL    PARESIS    IN    WHICH    SPONTANEOUS 
FRACTURES    OCCURRED. 

A  man,  £et.  43,  presented  himself  as  an  out-patient,  with 
a  fracture  of  both  bones  of  the  left  forearm.  Three  days 
before,  on  lifting  a  shovelful  of  dirt,  he  felt  a  slight  pain 
in  his  arm  and  heard  a  slight  cracking,  but  continued  his 
work.     The  manipulations  necessary  for  putting  the  arm 


HEMATOMA    AURIS.  l6l 

in  a  plaster  dressing  caused  him  no  pain.  He  returned 
five  weeks  later  to  have  the  plaster  removed ;  union  was 
complete.  At  the  same  time,  he  showed  his  right  arm 
and  examination  showed  that  the  two  bones  of  the  fore- 
arm were  broken.  He  had  slipped  on  a  flight  of  stairs 
and  in  falling  struck  the  back  of  his  hand,  not  very 
strongh^  on  some  coal  in  a  basket  that  he  was  assisting  in 
carrying.  In  this  case  also,  he  did  not  know  he  had 
broken  any  bones.  The  clinical  history  leaves  no  doubt 
that  he  was  a  general  paretic. 
The  points  of  interest  are  : 

1.  In  a  paretic, whose  disease  had  existed  over  six  months, 
two  spontaneous  fractures  occurred  at  intervalsof  fiveweeks. 

2.  These  fractures  caused  no  pain  to  the  patient  at  the  mo- 
ment of  their  production,  nor  at  the  time  of  their  reduction. 

3.  The  union  was  rapid,  as  has  already  been  noted  for 
this  class  of  fractures.  (Abstract,  Froelich,  American 
Journal  of  Psychology,  Vol.  5,  p.  84.) 

Hematoma"  Auris. — The  "  insane  ear,"  hematoma 
auris,  found  also  in  other  forms  of  insanity,  is  partic- 
ularly frequent  in  general  paresis.  It  occurs  occa- 
sionally in  sane  persons,  especially  in  those  engaged 
in  boxing,  playing  foot-ball,  or  wrestling,  but  under 
these  circumstances  it  heals  quickly. 

In  all  forms  of  insanity  the  prognosis  is  bad  after 
the  development  of  hematoma  auris.  Clouston  has 
seen  but  four  or  five  cases  recover  out  of  over  eighty, 
who  had  fullv  developed  hematoma  auris;  and  four 
others,  who  partiallv  recovered  after  slight  threaten- 
ings  of  hematoma,  \vhich  might  not  have  developed 
fully,  or  were  stopped  by  blistering  fluid.  Savage 
has  seen  but  one  case  in  which  a  patient  was  dis- 
charged \vell,  after  having  marked  hematoma.  None 
of  these  cases  of  recovery,  of  course,  were  paretics. 

It  consists  of  a  rapidly  developed  extravasation  of 
blood  into  an  intracartilaginous  cyst  of  the  auricle 
of  the  ear.     It  fills  the  pavilion  of  the  ear,  but  does 


l62 


PARTICULAR     SYMPTOMATOLOGY 


not  affect'^the  lobe;  it  grows  to  the  size  of  an  egg, 
sometimes  in  a  few  hours,  more  frequently  in  a  few 
days.  It  is  of  a  dark,  reddish-blue  color,  rarely 
lighter  in  shade  and  is  filled  with  a  gelatinous  sub- 
stance consisting  in  part  of  broken-down  blood. 
Difference  of  opinion  existed  as  to  where  the  disease 
is  situated,  Foville  saying  it  occurred  under  the  peri- 
chondrium, Mabillc  that  it  was  between  the  cartilage 
and  the  skin,  and  Vallon  that  it  was  in  the  body  of  the 

Fig.   3. 


Hematoma  ACRis.     (Williams.) 
a,  showing  the  distended  ear  ;  b,  showing  the  shrivelled  ear. 

cartilage.  The  latest  exposition  is  by  Ford  Robert- 
son.^ His  views  may  be  thus  expressed:  Hematoma 
auris,  to  which  the  insane  are  particularly  predis- 
posed, is  due  to  the  occurrence  of  certain  morbid 
changes  in  the  ear  cartilage.  They  consist  in  the 
degeneration  of  the  cells,  loss  of  the  elastic  fibers, 

'Path.  Ment.  Dis.,  p.  48. 


HEMATOMA    AURIS.  1 63 

and  breaking  down  of  a  portion  of  the  hyaline  basis 
of  the  cartilage,  so  that  a  cyst  is  formed.  New  capil- 
laries develop  in  the  walls  of  these  cysts.  The  new 
capillaries  are  very  prone  to  degenerative  changes, 
probably  identical  with  the  hyaline  fibroid  degenera- 
tion so  common  in  the  intracranial  vessels.  From 
rupture  of  these  new  capillaries  hemorrhage  into  one 
of  these  intracartilaginous  cysts  results.  The  rupture 
may  be  spontaneous,  but  usually  a  traumatism,  more 
or  less  severe,  initiates  the  effusion. 

The  tumor  heals  in  time  by  reabsorption,  but  if 
left  untreated  rupture  may  take  place  and  in  all  cases 
a  bad  deformity  remains.  If  treated  at  once  with 
blistering  fluid  absorption  takes  place,  the  size  de- 
creases, but  the  cartilage  usually  remains  hard  and 
shrivelled.  It  is  most  frequently  seen  in  the  second 
and  third  stages  of  paresis,  more  often  in  the  left  ear, 
and  is  rarely  found  in  women. 


CHAPTER   XIII. 

PARTICULAR    SYMPTOMATOLOGY    {conttJltCed) . 

Blood. — As  the  disease  develops  blood  examina- 
tions show  in  all  cases  a  diminution  in  the  amount 
of  hemoglobin.  The  richness  in  corpuscles  varies 
much,  according  to  Lewis,  from  75  to  126  per  hemic 
unit,  the  latter  register  in  cases  of  maniacal  excite- 
ment; but  since  a  diminution  in  the  number  of  red 
corpuscles  is  found  quite  as  often,  and  even  more 
frequentl}^,  in  maniacal  patients,  this  establishes  no 
connection  between  mania  and  the  corpuscular  rich- 
ness. However,  the  diminished  coloring  power  of 
the  corpuscle  is  of  importance  as  it  indicates  the 
lack  of  hemoglobin. 

In  the  third  stage  the  blood  becomes  fluid  and 
viscous,  and  coagulates  with  difficulty.  The  clot  is 
soft  and  diflluent,  and  tears  readily.  Sometimes 
angular  globules  and  crystals  of  urate  of  soda  are 
found,  and  Voisin  reports  in  some  cases  vibriones 
and  bacteria.  Lewis  ^  gives  an  interesting  table 
of  the  results  of  the  blood  analysis  of  fifteen 
cases  of  general  paresis  at  diflerent  periods  of  the 
disease. 

Temperature. — Many  conflicting  circumstances  pre- 
vent definite  statements  as  to  the  temperature  of 
paretics.  At  one  time  it  was  believed  that  the  reve- 
lations of  the  thermometer  were  of  the  utmost  im- 
portance in  the  study  of  the  disease.  But  frequently 
the  temperature  is  affected  by  the  presence  of  some 
intercurrent   disturbance,  bed-sores    and    local    lung 

'Mental  Diseases,  2d  ed.,  p.  326. 
16^ 


TEMPERATURE.  165 

complications  being  particularly  responsible  for  a  rise 
of  temperature.  Slightly  exciting  circumstances  may 
cause  a  rise,  while  a  transitory  change  of  temperature 
may  occur  without  any  apparent  mental  or  physical 
change,  so  that  fluctuations  of  temperature  due  to  mor- 
bid changes  of  the  malady  alone  are  difficult  to  secure. 

In  early  stages  very  little,  if  any,  increase  occurs  ex- 
cept in  the  acute  cases.  When  the  disease  advances 
rapidly  there  is  continued  higher  temperature,  and  in 
the  last  stage  of  the  disease,  if  uncomplicated,  in 
nearly  all  cases  the  morning  temperature  is  about 
one  hundred  degrees  and  the  evening  one  hundred 
and  one  or  two.  If  further  increase  or  sudden  varia- 
tion occurs,  it  is  apt  to  mark  the  advent  of  some  phys- 
ical trouble.  Loss  of  sensation  and  motor  power  is 
often  marked  by  higher  temperature.  Dr.  Macleod^ 
says  that  cases  of  fatty  degeneration  are  characterized 
by  high  temperature,  continuing  until  death;  while 
those  of  extreme  emaciation  are  sometimes  marked  by 
high  temperature  until  complete  relaxation  of  the 
sphincters  takes  place,  when  the  temperature  gradu- 
ally declines  to  the  end,  death  in  these  cases  seeming 
to  begin  in  the  extremities  from  deficient  circu- 
lation. 

In  cases  of  apoplectic  attacks,  or  epileptic  con- 
vulsions, the  temperature  rises  and  continues  high 
through  the  attack,  and  decreases  slowly  after,  to 
either  recovery  or  death.  The  rise  may  amount  to 
from  one  to  five  degrees,  according  to  the  severity 
of  the  case.  Fits  are  usually  accompanied  by  pro- 
fuse sweating,  unilateral  or  general,  and  this  sweat- 
ing tends  to  reduce  the  temperature  of  the  body. 
Mickle^  gives  the  temperature  record  of  a  case 
during   an  apoplectic  attack,  previous  to  which   the 

^  Bucknill  &  Tuke,  Psychological  Medicine,  p.  325. 
^General  Paralysis  of  the  Insane,  p.  179. 


1 66  PARTICULAR     SYMPTOMATOLOGY. 

temperature  had  been  normal.  It  rose  at  once  to 
103°,  and  gradually  fell  to  102°  in  twelve  hours;  on 
the  following  day  it  ranged  from  100.4°  ^^  98.8°. 
On  the  third  day  the  patient  recovered  from  the  at- 
tack. The  pulse  was  not  more  than  79  to  84  when 
the  temperature  was  at  the  highest. 

The  usual  condition  of  paretics  is  found  to  be  a 
normal  temperature  with  a  slight  evening  rise;  this 
continues  until  a  late  stage  of  the  disease.  Occa- 
sionally a  subnormal  temperature  is  found,  but  this 
is  rare.  In  cases  that  are  bright  and  active  in  the 
morning,  but  become  stupid  and  listless  and  have 
to  be  taken  to  bed  in  the  afternoon,  there  is  found 
to  be  no  rise  of  temperature  in  the  evening,  and  some- 
times a  fall  of  one  degree. 

After  a  study  of  twenty-live  cases,  Peterson  and 
Langdon  ^  say  that  as  regards  the  average  bodily 
temperature,  also  the  diurnal  oscillations  of  the  tem- 
perature of  paretics,  they  correspond  to  physiological 
norms;  that  the  axillary  differences  are  so  small 
that  they  cannot  be  considered  as  abnormal,  and  cer- 
tainly not  of  any  diagnostic  significance;  and  when 
variations  of  temperature  occur  in  general  paretics 
their  cause  must  be  sought  in  conditions  not  related 
to  the  pathological  phenomena  of  general  paresis, 
but  depending  upon  thermogenic  features,  not  recog- 
nized by  the  physician,  or  marked  by  the  mental 
state  of  the  patient.  In  this  report  they  do  not  in- 
clude a  study  of  temperature  in  connection  with  apo- 
plectic and  convulsive  seizures. 

ILLUSTRATIVE     OF     LACK     OF     RELATION    BETWEEN    TEM- 
PERATURE,   PULSE    AND    RESPIRATION    IN    PARESIS. 

A.  B.,  male,  set.  45  ;  American  ;  single  ;  lungs  and  heart 
normal.     Contracted  syphilis  in  1883  and  had  secondary 

*  Journal  of  Nervous  and  Mental  Diseases,  Vol.  18,  p.  750. 


TEMPERATURE.  1 67 

lesions  of  the  skin.  He  was  treated  for  syphilis.  Exciting 
causes  were  excessive  devotion  to  business  and  sexual 
excess.  He  showed  symptoms  of  mental  disturbance  in 
the  summer  of  1890  and  in  the  fall  an  eminent  alienist 
diagnosed  paresis.  Later  he  was  taken  to  Europe  for 
anti-syphilitic  treatment,  but  derived  no  benefit  mentally  or 
physically.  He  was  admitted  September  30,  1892,  in  the 
first  stage  of  paresis.  Early  in  June,  1894  (the  patient 
being  in  the  second  stage),  observations  showed  that  the 
temperature  was  usually  slightly  above  normal,  the  highest 
mark  being  100.2°  in  the  morning  after  the  patient  had 
slept  badly  and  had  been  very  violent  during  the  day. 
There  was  no  constant  ratio  between  the  temperature  and 
the  pulse  and  respirations.  From  June  8  to  14  a  tempera- 
ture of  100.3°  ^^'^^  obtained  after  a  convulsion  lasting 
twenty  minutes.  The  observations  were  renewed  in  Febru- 
ary, 1895.  The  patient  was  in  the  third  stage  and  confined 
to  his  room  in  his  chair,  but  later  was  bed-ridden.  The 
charts  of  the  temperature,  pulse  and  respirations,  cover- 
ing a  series  of  weeks,  show  that  their  relation  to  each  other 
and  to  the  temperature  is  more  variable  than  under  normal 
circumstances.  In  the  present  case  convulsions  and  the 
condition  of  the  bodilv  temperature  seem  entirely  indepen- 
dent of  each  other. 

In  this  case  both  general  and  localized  spasms  were  very 
frequent.  Spasms  of  one  or  both  eyelids  occurred  at  times 
without  any  other  convulsive  movement.  On  March  13 
there  was  spasmodic  closure  of  right  eyelid  for  three  hours, 
and  it  could  not  be  opened  except  by  force.  There  were 
also  spasmodic  contractions  of  the  laryngeal  muscles  fol- 
lowed by  cyanosis,  dyspnea  and  cough,  lasting  at  times 
four  or  five  minutes.  After  these  attacks  large  quantities 
of  mucus  would  be  secreted  which  the  patient  was  often 
unable  to  remove  himself.  During  these  attacks  the  tem- 
perature remained  very  low.  A  week  before  death  the 
patient  developed  a  mild  attack  of  bronchitis  and  secreted 
mucus  so  abundantly  that  he  was  almost  asphyxiated 
thereby.  On  April  16  a  temperature  of  95-4°  was  recorded 
during  a  convulsion.     There  was  no  difference  between 


1 68  PARTICULAR     SYMPTOMATOLOGY. 

the  temperatures  on  the  right  and  left  sides  of  the  body. 
On  April  24  complications  developed  and  as  a  result  there 
were  much  wider  oscillations  in  the  temperature,  pulse  rate 
and  respiration.  The  patient  died  May  i,  1895.  Con- 
vulsions had  occurred  almost  daily  between  February  21 
and  May  i.  (Abstract,  Parsons,  Journal  of  Nervous  and 
Mental  Diseases,  Vol.  20,  p.  410.) 

Pulse. — Frequently  the  pulse-rate  is  not  markedly 
changed,  rarely  it  is  slower  than  normal,  more  fre- 
quently slightly  increased.  In  the  early  stages  of  the 
active  form  often  a  very  high  tension  is  marked  by 
the  pulse ;  the  beat  of  the  heart  is  powerful,  the  first 
sound  clear  and  full,  the  second  accentuated.  In 
either  of  the  stages,  or  in  some  cases  from  the  first 
stage,  the  pulse  reveals  a  lessened  arterial  tension, 
or  has  the  usual  normal  qualities.  Toward  the  last 
stage  there   is  usuall}'  marked   cardiac   enfeeblement. 

Savage^  says:  "Having  taken  sphygmographic 
tracings  of  hundreds  of  cases  of  general  paralysis,  I 
have  come  to  the  conclusion  that  there  is  no  special 
pulse  which  can  be  said  to  be  in  any  way  associated 
with  this  disease.  In  a  few,  the  left  ventricle  acts 
with  undue  vigor,  as  if  to  overcome  some  general 
resistance  to  the  circulation;  and  in  a  few,  dis- 
tinctly febrile  symptoms  are  present;  but  the  pulse 
trace  pointed  to  nothing  which  can  be  in  any  way 
looked  upon  as  characteristic  in  most  cases  of  gen- 
eral paralytics."  Spitzka^  also  observes  that  "  the 
revelations  of  the  sphygmograph,  like  those  of  the 
thermometer  in  paretic  dementia,  are  of  high  sci- 
entific, but  not  of  any  great  diagnostic  value,  ex- 
cept indirectly  in  this  way — there  is  often  found  an 
irregular  and  coarsely  wavy  character  of  the  line  of 

^Of.  cit.,  p.  337. 

'Manual  of  Insanity,  p.  212. 


URINE.  169 

descent,  which  is  the  expression  of  the  irregular 
muscular  tremor  of  this  disease." 

The  Bladder. — Upon  the  appearance  of  spinal  symp- 
toms, showing  that  the  lumbar  cord  is  involved,  a  pa- 
tient is  never  free  from  the  possibility  of  bladder 
troubles. 

Retention  of  Urine. — This  condition,  when  it  ex- 
ists, demands  the  closest  watch,  for  if  not  relieved,  it 
may  lead  to  rupture  of  the  bladder.  The  possibility 
of  this  catastrophe  is  generally  enough  to  produce 
anxiety,  especially  in  asylums  where  paretics  are 
gathered  together. 

Chronic  C3^stitis,  or  spasmodic  contraction  of  the 
sphincter  urethrge  resulting  from  lumbar  irritation,  is 
a  common  cause  of  this  condition.  Again,  paral3'sis 
of  the  bladder  is  a  frequent  cause  of  retention.  Usu- 
ally accompanied  with  dribbling,  the  incontinence  or 
retention,  which  does  not  relieve  the  condition,  may 
mislead  the  physician  or  the  nurse.  Degeneration  of 
the  muscular  coats  of  the  bladder  sometimes  follows. 
Retention,  or  incontinence  is  only  transient  early  in 
the  disease,  if  present  at  all.  Moreover,  the  patient 
is  able  to  draw  attention  to  his  condition. 

Incontinence  of  urine  occurs  always  in  the  last 
stage,  and  is  a  cause  for  constant  care. 

Urine. — The  secretions  of  the  bod}^  are  altered  to  a 
varying  degree  in  general  paresis,  especially  as  the 
disease  progresses.  This  is  particularly  true  of  the 
urine,  which  beyond  doubt  acts  as  an  index  to  the 
alterations  in  the  nutritive  phenomena. 

In  the  earlier  stages  the  urine  will  show  little  of 
diagnostic  value.  An  occasional  trace  of  albumin 
may  be  detected,  which  is  most  likely  to  be  found 
after  a  convulsive  seizure.  The  specific  gravity  is 
usually  well  within  the  normal,  /.  e.j  1015-1025.  On 
account  of  the  general  tendency  to  excitement  in  the 


170  PARTICULAR     SYMPTOMATOLOGY. 

first  period  of  the  established  disease  one  would  ex- 
pect to  tind  an  increase  in  urea  and  the  chlorids,  the 
representatives  of  retrograde  metamorphosis  and  such 
proves  to  be  the  findings  very  generally. 

The  phosphoric  acid  is  diminished,  while  the  sul- 
phuric acid  is  about  normal.  It  is  but  rarely  that 
casts  are  found;  when  present,  they  are  of  the  hyaline 
variety.  No  great  significance  is  attached  to  the 
presence  of  these  bodies,  unless  they  persist,  or  are 
associated  with  casts  of  other  varieties,  /.  e,,  granular, 
epithelial,  etc.  There  is  no  constant  lesion  of  jthe 
kidney  present  during  the  disease  sufficient  to  result 
in  the  constant  presence  of  casts.  Wolfenden  (Lan- 
cet) states  that  Selmi  found  two  volatile  bases  in  the 
urine  of  patients  sufiering  from  general  paresis,  one 
like  nicotin,  the  other  like  coniin.  Other  observers 
have  noted  the  presence  of  acetone  and  peptone 
(Klippel  &  Servaux).^ 

An  excellent  report  b}-  Meeson  (West  Riding  Re- 
ports per  Sankey)"  gives  a  summar}-  of  the  urinary 
examinations  in  six  well-marked  cases. 

1.  The  quantity  of  urea  varies  above  and  below  the 
average  of  health,  being  in  the  majority  of  cases  con- 
siderably increased. 

2.  The  chlorids  and  phosphoric  acids  are  notably 
diminished,  the  sulphuric  acid  is  normal. 

3.  The  specific  gravity  varies  within  wider  limits 
than  in  health,  the  means  do  not  difter. 

4.  Absolute  quantity  estimated  according  to  the 
body  weight  is  slightly  in  excess  of  normal. 

In  the  terminal  stadium  the  great  difficulties  to  be 
overcome  in  securing  accurate  results  are  the  strong 
tendencies  to  alkaline  change  and  the  so-called  wet 
habits  of  the   patient.     Urea  estimation,  under  these 

'  Berkley,  Mental  Diseases,  p.  190. 
«  Op.  ctt.,  p.  275. 


URINE.  l^Jl 

circumstances,  is  in  reality  not  an  easy  or  very  satis- 
factory process,  and  the  results  often  anything  but 
accurate.  Turner^  has  shown  that  in  the  convulsive 
seizures  of  paresis  the  sulphates  are  found  in  excess 
in  the  urine. 

^  Journal  of  Mental  Science,  Vol.  41,  p.  14. 


CHAPTER   XIV. 

DIFFERENTIAL    DIAGNOSIS. 

The  symptoms  manifested  in  a  typical  case  of 
general  paresis  are  so  well  defined  that  it  is  not  diffi- 
cult, even  for  an  inexperienced  observer,  to  come  to  a 
definite  determination;  especially  is  this  true  of  the 
intermediate  stages  of  the  disease.  If  a  patient  is  first 
seen  in  the  latest  months  of  his  illness,  without  a  his- 
tor}'  of  the  previous  course  and  symptoms,  it  may  be 
impossible  to  distinguish  the  condition  in  which  he  is 
found  from  that  due  to  other  organic  lesions.  Again, 
at  the  earliest  onset  of  the  trouble,  when  the  symptoms 
are  slight  and  undecided  in  character,  there  is  often 
a  difficulty  in  diagnosis,  which  in  some  instances  can 
be  surmounted  only  b}'  an  acuteness  of  observation 
that  comes  to  one  of  experience  in  the  signs  of  men- 
tal and  nervous  disease. 

The  difficulty  in  diagnosis  arises  from  the  fact  that 
the  pathological  condition  is  a  general  and  indetermi- 
nate invasion  of  the  nervous  system,  appearing  often 
indiscriminate!}'  in  an}'  of  its  divisions.  This  gives 
rise  to  much  irregularity  and  variety  in  the  sympto- 
matology, both  psychic  and  physical,  and  a  conse- 
quent simulation  of  various  simpler  organic  disorders. 
As  Spitzka  remarks :  "  Among  the  individual  signs 
may  be  found  almost  any  and  every  focal  and  general 
symptom  known  to  the  neurologist."  According  to 
the  predominating  character  of  its  manifestations  the 
disease  has  been  divided  into  a  number  of  types,  and 
it  is  in  the  rarer  and  more  obscure  of  these  types  that 
we  find  the  greatest  difficulty.     Thus  there  are  cases 

173 


CHRONIC    ALCOHOLIC    INSANITY.  1 73 

in  which  melancholia  and  hypochondria  form  the  pre- 
vailing phase,  those  in  which  maniacal  excitement 
predominates,  and  those  where  dementia  exists  alone 
without  the  characteristic  excitement.  Spinal  symp- 
toms of  either  a  spastic  or  tabetic  nature  ma}'  obscure 
the  diagnosis  and  a  predominance  of  the  epileptiform 
and  apoplectiform  attacks  may  closety  simulate  con- 
ditions of  a  more  localized  origin,  i 

The  symptoms  upon  which  we  chiefly  rely  in  mak- 
ing a  diagnosis  of  general  paresis  are:  aftection  of 
speech,  pupillary  anomalies,  muscular  tremor,  and 
uncertain  gait,  accompanied,  on  the  mental  side,  by 
intellectual  weakness,  and,  in  many  cases,  by  delus- 
ions of  grandeur.  When  these  exist  in  combination, 
one  needs  no  further  assistance  in  the  recognition  of 
the  disease. 

We  will  touch  briefly  upon  the  principal  conditions 
which  may  be  mistaken  for  general  paresis,  mention- 
ing the  salient  points  which  enter  into  the  determina- 
tion of  a  correct  diagnosis  in  each  case. 

Chronic  Alcoholic  Insanity.  —  Closely  allied  in  some 
of  its  phases  with  general  paresis  is  the  form  of  in- 
sanity due  to  chronic  alcoholism.  In  considering 
this  we  must  bear  in  mind  its  etiological  connection 
with  the  disease  in  question,  as  well  as  the  fact  that 
the  two  conditions  may  exist  in  combination. 

It  is  the  type  of  paresis  in  which  the  mental  state 
is  most  marked  by  melancholic  depression  and  hypo- 
chondriasis which  most  closely  resembles  brain  dis- 
turbance due  to  alcohol.  The  delusions  of  a  perse- 
cutory nature  and  the  general  attitude  of  dread  and 
suspicion  which  mark  this  latter  disorder  are  very 
unlike  the  exhilarated  fancies  and  contented  calmness 
of  mind  found  in  a  typical  case  of  paresis.  The 
speech,  though  slurred  and  tremulous  like  that  of 
the    general  paralytic,  shows   a  thicker  enunciation 

15 


174  DIFFERENTIAL    DIAGNOSIS. 

and  is  without  the  characteristic  vocal  defects  of  that 
disease,  so  significant  to  the  practiced  ear.  The  tre- 
mor in  alcoholism  is  more  universally  distributed, 
and  not  first  noticed  in  certain  special  muscle  groups. 
The  sensorial  disorders  of  various  kinds  are  much 
more  prominent;  the  motor  symptoms,  including 
muscular  ataxia,  on  the  other  hand,  are  decidedly 
less  in  extension  and  are  not  of  the  steadily  progress- 
ive order  found  in  general  paresis. 

In  certain  cases  of  chronic  alcoholism,  which  symp- 
tomatically  closely  resemble  some  types  of  general 
paresis,  judgment  may  have  to  be  suspended  for  a 
time.  Where  the  excessive  use  of  alcohol  is  the  only 
factor  involved,  the  removal  of  the  stimulant  and  the 
effect  of  treatment  will  probably,  in  time,  determine 
the  diagnosis.  There  are  also  cases  of  acute  alco- 
holic mania,  which  so  closely  resemble  paresis  of  the 
maniacal  form,  that  time  alone  can  definitely  settle 
the  question. 

Syphilitic  Insanity.  —  Another  affection,  produced 
by  an  indeterminate  invasion  of  the  whole  system  is 
that  form  of  mental  disease  which  is  due  to  syphilis. 
Most  readily  confounded  with  it  are  those  cases  of 
general  paresis  in  which  dementia  is  the  chief,  or  an 
earl}'  symptom,  and  in  which  the  exaltation  is  but 
slightly  marked,  or  entirely  absent,  the  mental  state 
being  tinged  with  depression  and  fear. 

This  form  of  insanity  is  characterized  by  mental 
excitement  and  motor  restlessness,  passing  on  through 
stages  of  mental  enfeeblement,  with  muscular  inco- 
ordination and  paresis,  into  a  complete  dementia  and 
motor  paral3^sis.  An  early  and  rapid  decline  of 
memory  is  common  in  this  disease,  as  is  also  the 
occurrence  of  epileptiform  and  apoplectiform  attacks. 
Except  in  the  early  and  undefined  stages  of  either 
disease,  the   diagnosis   should   not   be   attended  with 


PARALYTIC    INSANITY.  1 75 

great  difficulty.  In  general,  the  much  longer  duration 
of  syphilitic  insanity,  the  irregularit}^  of  occurrence 
and  the  capricious  grouping  of  the  various  syinptoms 
are  characteristic  distinctions,  in  addition  to  the  effect 
obtained  by  specific  treatment. 

The  principal  symptoms  of  syphilitic  insanity,  which 
should  prevent  confusion,  are  the  intense  and  persist- 
ent caphalalgia,  worse  at  night;  the  early  well-defined 
apoplectiform  and  epileptiform  attacks,  with  their  pro- 
nounced and  permanent  after-effects;  the  tendency  to 
local  spasm,  followed  by  contractions  and  rigidity;  the 
optic  neuritis;  the  early  failure  of  the  special  senses, 
complete  rather  than  gradual;  the  early  and  localized 
anesthesise.  In  this  disease  the  purely  nervous  symp- 
toms precede  the  mental  signs.  The  state  of  mind  is 
one  of  great  irritability  and  depression  and  the  delu- 
sions, if  they  exist,  are  of  a  suspicious  or  persecutory 
nature. 

In  syphilis  we  find  paralysis  of  the  cranial  nerves, 
complete  and  not  necessarily  preceded  by  convulsion, 
unlike  the  more  incomplete  and  transitory  effects  of 
the  convulsive  attack  of  general  paresis.  The  motor 
impairment  is  paralytic  rather  than  paretic.  It  is 
apt  to  be  localized  and  unilateral,  and  it  is  stationary 
or  retrogressive  in  its  course.  The  ocular  symptoms 
are  often  intense,  being  an  extreme  double  optic 
neuritis,  or  a  severe  form  of  choroiditis,  followed 
frequently  by  sudden  blindness.  The  aflfection  of 
speech,  so  characteristic  in  general  paresis,  is  not 
found  in  syphilis,  nor  is  the  impairment  of  facial, 
lingual  and  pharyngeal  muscles  so  common,  and  when 
found,  it  is  almost  always  distinctly  paralytic  in 
character. 

Paralytic  Insanity,  or  Organic  Dementia. — In  this  form 
of  disease  there  is  a  progressive  enfeeblement  and 
diminution  of  mental   power,  generally  complicated 


176  DIFFERENTIAL    DIAGNOSIS. 

with  some  form  of  motor  paralysis.  The  mental 
symptoms  usuall}-  begin  as  a  mild  depression,  super- 
seded by  a  mildly  exalted  eondition  and  eombined 
with  a  childish  emotionalism.  The  final  state  is  one 
of  complete  forgetfulness  and  helpless  torpidity. 
This  being  not  a  primary  disease,  but  secondary  to 
brain  tumor  and  other  lesions,  the  symptoms  are 
irregular  and  vary  with  the  nature  of  the  lesion.  The 
various  S3'mptoms  are  non-progressive  in  course  and 
remain  stationary  for  3-ears,  the  duration  of  the  disease 
being  in  some  instances  many  years.  The  majority 
of  the  cases  occur  at  a  later  period  of  life  than  is 
common  with  general  paresis. 

The  enunciation  is  thick  and  paretic,  but  it  has  not 
the  tremulousness  found  in  general  paresis,  nor  the 
same  peculiarities.  Every  word  is  slurred,  or  im- 
perfectl}'  pronounced,  and  there  is  no  greater  hesi- 
tancy over  words  that  are  long,  and  made  up  of  con- 
sonants, than  over  the  shorter  vocal  sounds.  If, 
however,  the  primar}-  condition  be  an  apoplexy, 
involving  the  cerebral  convolutions,  the  speech 
symptoms  may  more  closely  resemble  those  of  the 
paretic.  Various  epileptiform  and  apoplectiform  at- 
tacks may  occur  during  the  course  of  the  disease,  and 
their  effects  are  more  persistent  than  the  sequelae  of 
similar  attacks,  occurring  in  the  course  of  the  con- 
trasted disease.  Among  the  motor  signs  are  various 
spasms  and  paralyses,  or  paretic  affections,  both  local 
and  general. 

In  many  cases  the  mental  symptoms  are  slight,  and 
obscured  by  the  much  more  prominent  sensory  com- 
plications. Where  the  primary  lesion  is  a  brain 
tumor,  the  marked  and  characteristic  symptoms  of 
that  affection  come  to  our  aid.  But  certain  cases  of 
cerebellar  tumor,  with  a  general  impairment  of  mus- 
cular   power,  a   swaying,  staggering,  tottering    gait, 


APOPLEXY.  177 

with,  possibly,  some  incoordination  of  muscular 
movement,  may  give  rise  to  great  difficulty  in  diag- 
nosis. In  such  cases  the  determination  must  rest 
upon  the  prominence  of  headache,  vertigo,  the  char- 
acteristic vomiting  and  ocular  defect. 

Epilepsy. — The  cases  of  paresis  in  which  the  con- 
vulsive seizure  is  a  frequent  prominent  and  early 
symptom,  mav  have  to  be  distinguished  from  cases 
of  genuine  epileps}',  but  this  should  not  be  difficult. 
The  easily  irritated  temper  of  an  epileptic,  with  the 
strong  impulsive  tendency  to  acts  of  violence,  is  very 
different  from  the  disposition  which  is  found  in  the 
general  paralytic,  although  there  are  cases  which  are 
markedly  of  this  opposite  nature. 

The  chief  points  of  difference  will  be  found  in  the 
stationary  condition  of  the  physical  and  mental  state 
between  the  attacks,  and  the  transitory  and  inconstant 
nature  of  any  effects  which  may  be  produced  by  the 
convulsions.  The  tendency  to  sleep,  or  semi-stupor, 
following  the  epileptic  fit,  differs  from  the  complete 
stupor  remaining  after  a  convulsion,  occurring  in  the 
course  of  general  paresis.  In  this  latter  disease,  each 
fit  is  followed  by  a  permanent  increase  in  mental 
symptoms,  out  of  all  proportion  to  the  severity  of  the 
spasm,  which  is  generally  unilateral,  and  may  occur 
in  a  limited  group  of  muscles  only.  Whereas,  the 
spasmodic  twitching,  in  an  epileptic  attack,  is  more 
generally  universal. 

The  speech  of  an  epileptic  is  slow,  and  in  long-con- 
tinued chronic  cases  may  be  thickened  and  tremulous, 
accompanied  by  a  jerky  tremor  of  the  lips  and  face 
during  speech ;  but  the  mental  and  physical  state  of  the 
patient,  between  the  attacks,  should  clear  up  any  doubt. 

Apoplexy. — There  are  several  points  which  serve  to 
separate  the  congestive  attack,  occurring  during  the 
course  of  general  paresis,  from  that  due,  primarily, 


170  DIFFERENTIAL    DIAGNOSIS. 

to  cerebral  hemorrhage.  As,  for  instance,  the  ab- 
sence of  stertorous  breathing  and  the  characteristic 
puffing  out  of  the  cheeks.  After  the  attack,  the  para- 
lyzed limbs  are  left  rigid  and  frequently  in  a  state  of 
violent  action,  not  flaccid  and  relaxed,  as  in  apo- 
plexy. The  transitory  congestive  symptoms  quickly 
pass  awa}',  leaving  a  permanent  aggravation  of  the 
diseased  condition,  in  its  physical  or  mental  aspect, 
or  in  both. 

The  customary  rise  of  temperature,  during  or  pre- 
ceding the  attack,  is  in  marked  contradistinction  to 
the  subnormal  temperature  of  a  true  apoplexy;  the 
paralyses,  resulting  from  which,  are  of  much  longer 
duration  and  more  strictly  limited  in  extent  and  dis- 
tribution. 

Acute  Mania  with  Delusions. — There  are  cases  of  acute 
mania  marked  by  false  ideas  of  personal  grandeur, 
power  or  wealth,  which,  especially  when  complicated 
with  some  defect  in  speech,  or  tremulousness  of  the 
facial  muscles,  may  be,  for  a  time,  exceedingly  diffi- 
cult to  distinguish  from  those  cases  of  general  paresis, 
in  which  maniacal  delirium,  and  outbursts  of  fury, 
play  a  prominent  part.  It  may  be  impossible  to  make 
a  definite  diagnosis,  until  after  the  subsidence  of  the 
acute  outburst. 

The  brief  duration  and  sudden  cessation  of  such  an 
attack  in  general  paresis,  leaving  the  various  delusions 
still  prominent,  together  with  a  marked  amnesia  and 
mental  weakness,  is  in  strong  contrast  to  the  slow 
and  gradual  recovery  of  true  mania,  with  the  lucidity 
of  mind  and  extraordinary-  acuteness  of  memory,  that 
mark  the  convalescent  period.  The  gusts  of  rage  and 
suspicious  aversion  are  transitory  and  easily  diverted 
in  general  paresis,  and  there  is  not  that  tendency  to 
violence  and  malicious  acts,  as  an  essential  part  of 
mania  per  se. 


SENILE     INSANITY.  1 79 

While  the  delusions  of  an  acute  mania  may  assume 
an  exalted  and  self-satisfied  nature,  the  tremendous 
exaggeration  common  to  general  paresis  is  wanting, 
and  this  is  considered  by  some  to  be  an  important 
and  valuable  point  in  the  diagnosis.  The  delusions  of 
monomania,  fixed  in  character  and  logically  reasoned 
out,  being  due  to  a  perversion  of  intellect,  not  simply 
the  exaggerations  of  an  imagination  uncontrolled  by 
reason,  can  raise  no  question  in  the  mind  of  the  care- 
ful observer.  The  tenacity  with  which  they  are  held 
is  in  striking  contrast  to  the  shifting  and  easily  diverted 
mental  processes  of  the  paretic. 

Senile  Insanity.  —  Cases  of  senile  insanity,  which 
may  present  symptoms  strongly  suggestive  of  general 
paresis,  are  usually  made  clear  by  the  advanced  age 
at  which  they  occur.  General  paresis  is  rarely  found 
in  subjects  after  sixty  years  of  age.  While,  on  the 
other  hand,  there  have  been  cases  of  undoubted  pare- 
sis, which  have  occurred  in  the  aged;  and  some  of 
unusual  duration  which  have  been  found  in  advanced 
life.  The  cases  of  mild  maniacal  exaltation,  coexisting 
with  delusions  of  great  possessions  and  power,  to- 
gether with  changes  in  speech,  are  sometimes  found 
to  be  cases  of  general  paresis  in  the  aged.  But  the 
senile  speech  is  not  the  typical  defect  of  paresis  due 
to  convolutional  decay.  It  is  rather  a  combination 
of  the  loss  of  muscular  power  and  mental  quickness, 
due  to  failing  faculty;  and  it  is  characterized  by  a 
combination  of  aphasic,  amnesic  and  paretic  symp- 
toms. This  gives  rise  to  a  slight  indistinctness,  from 
imperfect  muscular  power  and  incoordination,  with  a 
difficulty  in  finding  words,  and  a  tendency  to  omit 
parts  of  a  sentence,  especially  the  nouns.  There  is 
no  accompaniment  of  a  fibrillar  trembling  of  the  facial 
and  labial  muscles.  The  advanced  dementia  found 
in  senile   cases   is  distinguished    by  the  absence  of 


l8o  DIFFERENTIAL    DIAGNOSIS. 

motor  symptoms,  such  as  tremor  or  paresis,  and  by 
its  non-progressive  and  stationary  character,  and  its 
comparatively  long  duration. 

Tabes  Dorsalis. — In  the  cases  where  the  spinal  cord 
is  involved,  or  is  the  seat  of  the  disease,  we  may 
have  a  condition  strongly  suggestive  of  a  tabes  dor- 
salis. There  may  be  an  exaggeration  of  the  deep 
tendon  reflexes  with  a  paralysis,  spastic  in  type,  or  as 
frequently,  a  marked  impairment  of  knee-jerk  and 
ankle  reflex,  associated  with  a  tabetic  gait,  and  other 
s3'mptoms,  closely  simulating  this  disease,  but  tran- 
sient in  duration.  The  other  and  distinctive  symp- 
toms are,  however,  so  marked  that  a  differentiation  is 
not  difficult. 

Disseminated  Sclerosis.  —  The  lesion  of  a  dissemi- 
nated sclerosis,  being  general  and  irregularly  dis- 
tributed, gives  rise  to  numerous  symptoms  similar  in 
nature  and  localization  to  those  of  general  paresis. 
Such  are  the  muscular  paresis,  tremor,  speech  affec- 
tion, etc.  But  the  staccato  quality  of  the  enunciation 
should  not  be  confounded  with  the  slurred  drawling 
speech  of  paresis,  except  by  observers  of  limited 
experience.  Then,  too,  the  tremulousness  present  is 
a  decided  "  intention  tremor,"  and  is  distinguished  by 
its  coarser  quality  and  greater  excursion.  Nystag- 
mus is  a  frequent  and  significant  symptom,  in  addi- 
tion to  the  bulbar  paralysis  and  muscular  rigidity  and 
contractures.  There  is  only  a  late  development  of 
mental  symptoms,  if  any  appear. 

Lead  Poison.  —  The  epileptic  seizures  and  loss  of 
memory,  which  often  occur  in  cases  oi  lead-poison- 
ing, ma}'  give  rise  to  some  suspicion  of  a  paretic  con- 
dition, if  the  other  symptoms  and  the  history  of  ex- 
posure and  invasion  are  not  clear.  Especially  would 
this  be  so  in  those  cases,  where  a  delirium,  either 
maniacal  or  melancholic,  terminates  in  a  dementia  of 


PARALYSIS   AGITANS.  l8l 

an  extreme  degree.  The  occurrence  of  the  char- 
acteristic wrist-drop,  the  discoloration  of  the  skin 
and  the  blue  line  on  the  gums  would  determine  the 
case.  To  these  may  be  added  the  greater  promi- 
nence of  sensory  symptoms,  anesthesia,  etc.,  together 
with  a  total  failure  of  muscular  response  to  the 
electric  current. 

Paralysis  Agitans.  —  Some  cases  of  general  paresis 
have  a  symptomatic  paralysis  agitans  occurring  in 
their  course;  or  paralysis  agitans  ma}'  be  complicated 
with  an  affection  of  speech  and  muscular  weakness,  a 
stolidity  of  feature  and  a  slowness  of  movement  not 
unlike  the  condition  seen  in  the  former  disease.  The 
history  of  the  case  should  decide  it,  as  the  paralytic 
tremor,  when  seen  in  paresis,  always  follows  its  more 
characteristic  mental  and  motor  s3'mptoms. 

A    CASE    OF    GENERAL    PARESIS    ILLUSTRATIVE    OF 
DIAGNOSIS. 

A  case  remained  for  some  time  in  doubt  and  presented 
in  its  early  stages  S3'mptoms  by  no  means  characteristic  of 
general  paralysis.  The  patient  was  brought  to  the  asylum 
with  insanity  of  only  a  few  days'  duration.  He  had  been 
riding  on  the  pavement,  assaulting  the  police,  and  he  was 
incoherent  and  rambling.  He  said  the  sun  was  turned  into 
the  moon,  and  such  things  ;  he  had  no  grandiose  delusions  ; 
he  was  frequently  taciturn,  not  speaking  perhaps  for  a  whole 
day.  On  alternate  days  his  condition  varied ;  on  one  he 
was  dull  and  depressed,  refused  his  food  and  would  not 
speak  ;  on  the  other,  he  was  gay  and  excited.  He  had  few 
delusions  and  he  said  little  except  that  he  "  wanted  to  go." 
He  was  wet  and  dirty  ;  he  had  no  stutter.  The  signs  of  gen- 
eral paralysis  were  mostly  absent  but  there  was  irregularity 
of  pupils  and  great  defect  in  memory.  In  six  months  he  got 
so  much  better  that  he  went  into  the  country  with  his  wife 
and  was  reported  to  be  quite  well.  When  readmitted  in 
the  following  year  the  signs  of  general  paralysis  were  well 

i6 


l!52  DIFFERENTIAL    DIAGNOSIS. 

marked.  His  sons  were  dukes,  he  was  worth  millions, 
etc.  At  the  commencement  only  the  irregularity  of  pupils, 
defect  of  memory  and  general  absent-mindedness  made  the 
prognosis  unfavorable.  He  complained  constantly  of  pain 
in  the  head.  When  said  to  be  recovered  he  remained  in 
the  country  idle  ;  the  moment  he  resumed  work  the  symp- 
toms returned  and  with  unmistakable  features  of  the  dis- 
order. (Abstract,  Blandford,  Insanity  and  Treatment,  p. 
303-) 

AN    ILLUSTRATION    OF    EARLY    DIAGNOSIS. 

Mr.  ,   a   druggist,   38    years   old.     Three   or  four 

years  ago  he  began  to  show  a  want  of  aptitude  in  his  work, 
which  had  been  slowly  increasing.  He  had  also  moderate 
pains  in  his  legs  and  occasional  headaches,  for  which  he 
began  to  dose  himself  extravagantly.  He  attended  to 
business  closely,  although  he  had  excellent  clerks,  and 
nothing  happened  amiss.  His  clerks  and  family,  and  then 
customers  began  to  notice  absent-mindedness  and  inatten- 
tion in  him.  His  father-in-law,  an  intelligent  wholesale 
druggist,  thought  he  must  be  taking  morphine.  Without 
giving  any  reason  for  his  actions  he  stopped  going  to 
church  and  to  the  choir  of  which  he  was  leader,  and  made 
false  statements  due  to  confusion  or  impaired  memory  and 
attention.  He  was  pliant,  dull,  apathetic,  with  lessened 
animation  in  his  expression  and  conduct,  showing  inertia 
and  weariness  on  moderate  exertion.  He  lost  forty-seven 
pounds  in  spite  of  a  voracious  appetite  and  abundant  nutri- 
tious food.  There  was  moderate  tremor  of  hands  and 
tongue  but  no  more  than  is  often  seen  in  neurasthenia. 
His  articulation  was  slow.  He  readily  gave  up  his  busi- 
ness and  went  to  an  asylum,  where  he  died  with  typical 
symptoms  of  general  paresis.  (Abstract,  Folsom,  loc.  cit.y 
p.  17.) 

A  CASE  OF  GENERAL  PARESIS  ILLUSTRATIVE  OF  DIAGNOSIS. 

A  clergyman,  had  an  exacting  city  parish  ;  with  the  age 
and  physique  in  which  general  paresis  prevails.  After  ten 
years'  service  it  was  found  that  judgment,  common  sense 


ILLUSTRATIVE    OF    DIAGNOSIS.  1 83 

and  notions  of  propriety  were  very  slightly  impaired ; 
he  was  easily  irritated,  fatigued  by  bodily  exercise,  restless, 
inattentive,  almost  indifferent ;  finally  he  called  for  the  same 
hymn  three  times  and  did  not  notice  the  slip.  Often  he  had 
dizziness  and  headache ;  the  more  he  wrote  the  worse  his 
writing  became.  He  was  sent  to  the  country  to  rest  for 
two  years  ;  he  improved  somewhat,  but  did  not  regain  his 
previous  intellectual  power.  Gait  became  heavy,  knee- 
jerk  exaggerated  ;  face  lost  animation  and  expression.  He 
took  a  small  parish  where  the  demands  made  upon  him  are 
light  and  he  has  preached  for  three  years  without  com- 
plaint. If  tired  his  gait  is  unsteady  ;  he  cannot  make  him- 
self heard  in  a  large  hall ;  he  has  less  serious  views  of  life. 
(Abstract,  Folsom,  loc.  cit.,  p.  15.) 

A    CASE    OF    GENERAL    PARESIS    EXHIBITING    TYPICAL    FEA- 
TURES   IN    DIAGNOSIS. 

Mr.  Z.,  set.  38  ;  lawyer  ;  on  admission  he  was  well  devel- 
oped ;  all  vital  organs  but  stomach  in  good  condition.  He 
has  indigestion  most  of  the  time  ;  he  is  irritable  and  suspi- 
cious ;  he  says  he  is  ill-used  by  his  family ;  he  has  lost  the 
power  to  work  ;  tremor  of  tongue  when  protruded  with  in- 
volvement of  muscles  of  expression ;  speech  scanning ; 
articulation  of  labials  difficult ;  pupils  normal  but  are  very 
mobile  and  dilate  widely  under  excitement ;  reflexes  nega- 
tive. History  :  He  was  brighter  as  a  boy  than  his  brothers 
and  in  good  physical  health.  He  was  never  on  good  terms 
with  his  family  because  they  did  not  appreciate  his  intel- 
lectual capacity.  After  leaving  college  he  had  diphtheria, 
leaving  him  profoundly  prostrated,  from  the  effects  of  which 
he  did  not  recover  for  more  than  a  year.  He  began  to 
practice  law  successfully  and  also  entered  politics,  which 
led  him  into  convivial  habits  and  he  became  addicted  to 
alcohol.  After  being  defeated  in  an  election  he  gave  up 
practising  law  and  took  up  other  business,  working  from 
8  A.  M.  till  II  P.  M.  for  eighteen  months.  After  finish- 
ing this  he  was  much  incensed  because  he  thought  his 
work  was  not  properly  valued.  He  left  his  native  city  and 
entered  a  Western  firm  where  he  did  not  get  along  well 


184  DIFFERENTIAL    DIAGNOSIS. 

either,  always  accusing  them  of  cheating  and  not  appreci- 
ating his  work.  Three  3'ears  ago  he  began  to  show  unusual 
irritability  and  a  disposition  to  quarrel ;  he  would  become 
violently  angry  for  trivial  causes ;  his  self-consciousness 
was  morbidly  developed  ;  he  was  very  egotistic  and  suspi- 
cious. Since  then  all  these  qualities  have  become  more 
prominent.  He  thinks  he  is  not  properly  treated  by  his 
family  or  employers.  There  is  no  history  of  insanity  in 
the  family,  although  his  father  was  morose  and  eccentric 
and  his  brother  became  insane  on  account  of  an  accident. 
Mr.  Z.  has  been  conscious  of  a  failing  power  to  work  and 
has  resorted  to  alcohol  to  keep  himself  up  and  drown  his 
bitter  feelings.  He  also  used  tobacco  immoderately.  He 
has  suffered  with  indigestion,  with  flatulence  and  fugitive 
pains  in  the  stomach,  back  and  head.  For  the  first  month 
after  admission  he  was  irritable,  cynical  and  morose,  alter- 
nately excited  and  depressed,  railing  at  his  family  and 
friends,  criticising  the  stupidity  of  every  one.  During  the 
following  year  there  was  progressive  mental  and  physical 
failure ;  impairment  of  memory  and  attention ;  loss  of 
physical  power ;  growing  paresis  of  facial  muscles  ;  ex- 
plosive laughter  and  weeping  with  exacerbation  of  excite- 
ment ;  no  hallucinations  or  delusions  ;  he  was  constantly  try- 
ing to  excite  sympathy.  He  applied  to  various  lawyers  to 
institute  proceedings  for  his  discharge.  When  by  himself 
he  would  talk  over  his  grievances,  cursing  family,  doctors, 
etc.  He  was  very  unhappy,  but  never  violent.  He  was 
constantly  trying  to  induce  newspapers  and  lawyers  to 
expose  the  management  of  the  insane  asylum,  but  would 
not  appear  personally  in  the  matter.  His  handwriting 
deteriorated  ;  sometimes  a  letter  would  be  omitted  or  the 
last  letter  of  a  word  would  end  in  a  scrawl.  The  lines 
became  uneven  and  wavy  and  with  intervals  so  that  they 
looked  like  a  series  of  dashes.  He  wrote  with  many  flour- 
ishes and  spoke  very  deliberately.  Soon  afterward  he 
managed  to  escape  and  he  is  now  in  a  sanatorium,  from 
which  place  he  is  sending  out  letters,  asking  newspapers, 
etc.,  that  they  expose  the  mismanagement  of  insane  asy- 
lums.    (Abstract,  Tomlinson,  loc.  a't.,  p.  778.) 


ILLUSTRATIVE    OF    DIAGNOSIS.  1 85 

A    CASE    OF    GENERAL     PARESIS     ILLUSTRATING     DIAGNOSIS 
IN    THE    EARLY    STAGE    OF    THE    DISEASE. 

A  senior  partner  in  successful  commercial  house  ;  strong 
constitution,  healthy,  50  years  old  ;  laryngologist  consulted 
because  it  was  thought  he  could  not  speak  so  clearly  as 
formerly ;  no  local  trouble,  supposed  to  be  nervous.  He 
attended  to  his  routine  duties  well,  but  became  tired  early 
in  the  day,  and  was  irritable  and  meddling.  His  talk  was 
not  always  to  the  point  but  there  was  nothing  to  suggest 
mental  trouble.  He  could  not  take  up  new  work  readily, 
or  remember  recent  stories  ;  in  some  small  matters  at  home 
he  became  careless  and  inattentive.  When  giving  orders 
across  a  large  room  his  voice  was  raised  as  if  in  effort,  and 
the  sentences  came  out  explosively  ;  was  diagnosed  a  gen- 
eral paretic  and  advised  to  go  to  Europe.  In  this  he  was 
pliant,  almost  indifferent.  He  was  well  behaved  on  the 
steamer.  In  England  and  France  he  showed  lack  of  in- 
terest and  became  dull  and  inactive  ;  articulation  became 
less  clear;  he  was  irritable,  and  easily  tired.  After  return 
he  went  to  a  summer  resort  where  he  showed  delirium  at 
night  with  delusions  and  some  violence  ;  also  incoherence 
and  thickness  of  speech.  Diagnosis  doubted  because  of 
continued  business  ability,  but  he  finally  presented  a  typ- 
ical case  of  general  paresis  and  died  in  two  or  three  years. 
(Abstract,  Folsom,  loc.  cit.,  p.  9.) 

A    CASE    OF    GENERAL    PARESIS    IN    WHICH    THE    DIAGNOSIS 
AND    ETIOLOGY    WERE    COMPLICATED    AND    INTERESTING. 

C.  D.,  admitted,  get.  35,  with  symptoms  of  general  par- 
esis ;  he  was  one  of  a  family  of  eight  children  of  hard- 
working, steady  parents.  He  was  in  school  for  a  short 
time,  then  became  a  plumber,  working  at  it  very  hard ;  he 
was  good  looking,  well-nourished  and  strong.  In  his  youth 
he  was  given  to  alcoholic  and  sexual  excesses.  After  his 
marriage,  at  26,  he  was  less  alcoholic  but  sexual  excess 
continued.  He  was  always  a  busy,  unrestful]  man,  and 
a  capable  workman.  Three  months  before  marriage  he 
worked  at  a  job  for  a  week  night  and  day  in  extreme  heat : 


1 86  DIFFERENTIAL    DIAGNOSIS. 

his  illness  was  dated  from  this  time.  Again  he  worked 
at  a  similar  job  eighteen  months  after  marriage.  After 
finishing  the  job  he  came  home  "  blue  in  the  face  "  and 
"fainted";  soon  after  he  suffered  from  lead-poisoning. 
For  four  years  he  did  nothing,  then  started  a  shop,  but 
soon,  after  much  worry  and  chagrin,  all  his  means  were 
gone.  Afterwards  he  was  a  successful  cabman  until  he  was 
thrown,  breaking  a  leg  and  getting  a  severe  blow  on  the 
head.  Towards  the  end  of  his  treatment  in  the  hospital  he 
became  manifestly  insane.  (Abstract,  Wilson,  G.  R., 
Journal  of  Mental  Science,  Vol.  38,  p.  40.) 


CHAPTER   XV. 

ETIOLOGY. 

While  a  large  amount  of  definite  knowledge  has 
been  the  product  of  extensive  investigations  into  the 
etiology,  clinical  history  and  pathology  of  this  dis- 
ease, there  remains  much  to  be  explored  in  these  sev- 
eral fields,  and  even  at  this  late  day  it  may  be  said 
that  the  comparative  value  of  many  vexatious  ele- 
ments continues  to  be  a  subject  of  dispute.  Doubt- 
less the  following  concise  summary  of  causes  as 
given  by  Chapin^  finds  wide  concurrence:  "  The  his- 
tory of  the  large  majority  of  cases  is  one  of  intemper- 
ence,  licentiousness,  sexual  excess,  syphilis  or  some 
nervous  exhaustion  incident  to  excessive  application 
to  business,  or  the  great  strain  attending  reverses." 
This  view  to  be  acceptable  to  some  authors  needs  to 
be  qualified  by  the  revision  that  the  results  of  hered- 
ity should  be  acknowledged  as  an  important  predis- 
posing cause.  There  are  prominent  writers  who 
claim  syphilis  as  the  sole  etiological  factor;  again, 
others  (and  they  appear  to  be  numerous)  who  estab- 
lish this  "unitarian"  view  on  a  neuropathic  basis, 
meaning  by  this  term  a  susceptibility  to  an  invalid 
brain,  which  may  be  either  inherited  or  acquired. 

Heredity.  —  Among  the  general  insane  a  history  of 
insanity  in  previous  generations  is  variously  estimated 
as  from  30  to  90  per  cent,  of  the  cases;  in  general 
paresis  the  usual  statistics  show  that  the  hereditar}^ 
character  of  this  malady  is  not  so  marked  as  that  of 
some  other  forms  of  insanity.     Some  writers  place  it 

'  Compendium  of  Insanity,  p.  177. 
187 


105  ETIOLOGY. 

as  low  as  lo  per  cent,  and  others  as  high  as  70 
per  cent.  There  are  extreme  views  not  confined  to 
these  limits.  Krafft-Ebing,  for  instance,  maintains 
that  the  predisposition  is  usually  acquired  and  not 
hereditary,  and,  on  the  contrary,  Nache  believes  that 
in  a  majority  of  paretics  the  brain  is  defective  from 
birth,  and  when  to  this  is  added  the  other  great  fac- 
tor— syphilis — the  result  is  not  far  to  seek.  Berkley 
holds  the  same  view,  basing  his  opinion  upon  the 
errors  of  development  of  brain  convolutions  and  of  the 
defective  growth  of  the  hemispheres,  and  especially 
upon  the  microscopical  evidences  of  irregular  con- 
struction and  anomalies  in  the  cortical  cells. 

Folsom  says :  "  Aly  experience  leads  me  to  the 
conclusion  that  in  those  cases  of  general  paresis 
without  a  previous  histor}'  of  syphilis  the  vast 
majority  occur  in  families  in  which  there  have  been 
cases  of  insanity,  epilepsy  or  apoplexy."  Regis 
thinks  the  most  important  predisposing  cause  of  gen- 
eral paresis  is  the  congestive  or  cerebral  tendency, 
usually  the  result  of  heredity.  He  adds  that  the  dis- 
ease has  its  source  in  an  heredity  that  is  not  vesanic 
but  cerebral,  arthritic,  or  congestive  and  cites  as 
authorit}'  Lunier,  Doutrebente,  Baillarger,  Ball, 
Lemoine  and  Pierret.  As  to  paretics  who  are  the 
offspring  of  insane  parents  he  notes  that  this  particu- 
larity shows  itself  in  the  vesanic,  remittent  or  circu- 
lar form,  that  is  to  say,  "  It  is  imposed  on  general 
paresis  by  the  predominance  in  the  subjects  of  the 
paral3'tic  insanity  over  the  paralytic  dementia." ' 
He  speaks  also  of  having  found  many  times  consan- 
guinit}'  in  the  ancestors  of  general  paretics. 

The  family  history  in  all  types  of  insanity  is  always 
of  importance,  for  while  the  disease  may  not  reappear  in 

^  In  explanation  of  this  view,  it  must  be  kept  in  mind  that  this  author 
holds  to  the  dual  theory  of  the  disease. 


HEREDITY.  1 89 

the  same  form,  a  record  especially  of  apoplexy,  epi- 
lepsy, or  alcoholism,  should  put  the  physician  on  his 
guard ;  for  there  can  be  no  doubt  that  defect,  deteri- 
oration, or  vitiated  quality  of  brain,  the  necessary  re- 
sults of  these  conditions,  are  strong  predisposing 
agents  toward  paresis.  And,  on  the  other  hand, 
from  paresis  is  transmitted,  not  usually  a  tendency  to 
the  same  disease,  but  a  general  tendency  to  organic 
and   functional   mental    disorders. 

The  percentage  of  heredity  is  lower  in  private  than 
in  pauper  cases,  and  lower  in  males  than  in  females. 
One  fact  should  be  noted  in  this  connection,  that 
paretics  usually  leave  small  families;  about  one-third 
of  the  marriages  are  sterile  and  the  families  of  the 
remaining  two-thirds  average  only  one  and  one-half 
child. 

GENERAL    PARESIS    DUE    TO    HEREDITARY    INFLUENCES. 

Twin  brothers,  with  a  strong  family  history  of  insanity, 
both  sanguine  and  keen  in  temperament,  of  very  active 
habits,  both  indulging  to  great  excess  in  wine  and  women  ; 
both  following  a  similar  occupation — an  exciting  one — and 
both  were  affected  with  general  paresis  within  a  year  of 
one  another.  (Abstract,  Clouston  &  Savage,  Journal  of 
Mental  Science,  Vol.  34,  p.  65.) 

BOTH    PARENTS    WERE    ALCOHOLICS. 

Two  brothers  under  treatment  for  general  paresis,  their 
father  was  an  alcoholic  and  died  of  cerebral  apoplexy,  their 
mother,  a  highl}^  educated  woman  of  violent  temper,  was 
also  an  alcoholic.  In  one  of  them  the  disease  was  attributed 
to  sun-stroke.  They  were  of  good  physique,  keen, 
ambitious  and  passionate,  both  alcoholic  and  one  of  them, 
at  least,  excessively  sexual.  They  followed  the  same 
occupation,  a  very  trying  and  exciting  kind  of  life  and  were 
conspicuously  successful.  Both  acquired  general  paresis 
between  the  ages  of  forty  and  forty-five  years.  (Abstract, 
G.  R.  Wilson,  Journal  of  Mental  Science,  Vol.  38,  p.  33.) 


190  ETIOLOGY. 

BOTH    PARENTS    WERE    ALCOHOLICS. 

A.  B.'s  ancestors  had  had  numerous  breakdowns  from 
neuroses  of  the  higher  levels.  His  father  was  a  shrewd, 
steady,  successful  business  man ;  his  mother  an  energetic 
pious  wife.  He  had  a  full  cousin  of  both  sides  who  died 
in  the  Crichton  Institution,  Dumfries.  The  fathers  were 
not  strikingly  alike  but  the  mothers  were.  At  the  height 
of  a  busy,  immoral  life  the  case  ended  in  general  paresis. 
(Abstract,  G.  R.  Wilson,  loc.  cit.,  p.  34.) 

A    CASE    OF    GENERAL    PARESIS    IN    A    DEGENERATE. 

Young  man  of  25,  always  regarded  as  simple-minded, 
but  tall  and  well  developed,  after  business  worry,  mani- 
fested considerable  exaltation,  followed  by  a  period  of 
comparative  well-being,  with  "faulty  and  slight  mental 
enfeeblement,"  succeeded  by  a  state  of  acute  resistive 
excitement,  ending  fatally.  (Abstract,  Hotchkis,  R.  D., 
Glasgow   Medical  Journal,  June,  1897.) 

DEGENERATION    AND    GENERAL    PARESIS. 

A  degenerate  man,  under  M.  Magnan's  care  for  some 
time,  who  developed  general  paralysis,  was  ultimately 
admitted  under  Professor  Joffroy's  care  as  an  illustration  of 
the  view  which  he  holds,  that  a  morbid  heredity,  more  or 
less  marked,  or  degeneration  more  or  less  obvious,  is  a  fre- 
quent if  not  indispensable  factor  in  the  etiology  of  general 
paralysis. 

The  patient,  a  foundling  born  in  185 1,  of  feminine  build 
and  habits  in  youth,  became  strongly  addicted  to  sodomy 
after  the  age  of  15,  and  led  a  life  of  debauchery  in  Paris. 
In  1893  his  memory  began  to  fail  and  he  was  arrested  for 
occupying  some  one  else's  bed  (mistaking  ( ?)  the  story  of  the 
house).  He  was  sent  to  the  asylum  ;  delusions,  loss  of 
memory,  unequal  pupils  and  slight  affection  of  speech  were 
noticed. 

In  May,  1895,  he  came  under  Professor  Joffroy's  care. 
His  condition  did  not  vary  much  till  1897,  during  which 
interval  he  had  been   working  as  a  tailor  in  the  asylum, 


HEREDITY.  I9I 

now  he  became  more  and  more  demented  with  fleeting 
delusions.  In  November,  1897,  he  took  to  his  bed,  and 
had  general  tremors  with  dirty  habits.  In  January,  1898, 
his  speech  became  incomprehensible  and  he  died  after 
getting  weaker  physically  and  intellectually,  in  March, 
1898.     (Abstract,  Revue  de  Psychologic,  98,  No.  10.) 

THE    DAUGHTER    OF    A    PARETIC    INHERITS    TABES. 

Heredo-tabes  in  a  young  girl  with  marked  congenital 
syphilis  whose  father  died  of  general  paralysis  but  with  no 
history  or  signs  of  syphilis.  (Abstract,  Mott,  Journal  of 
Mental  Sciences,  Vol.  55,  p.  693.) 

A  PARETIC  THE  SON  OF  AN  INSANE  FATHER  AND  PARETIC 

MOTHER. 

J.  R.  B.,  get.  38,  married,  no  children,  a  hard  drinker, 
developed  general  paresis  which  made  slow  progress ; 
father  died  of  acute  mania,  mother  of  general  paresis. 

A     CASE     OF     PARESIS     WITH     A     NEUROPATHIC     DIATHESIS. 

J.  H.,  aged  32,  married,  no  children.  First  attack, 
duration  two  years  ;  he  was  admitted  in  February  and  died 
in  October.  He  was  a  hard  drmker  ;  grandfather  insane  ; 
his  father  a  steady  man,  died  of  phthisis. 

A    CASE    OF    PRECOCIOUS    GENERAL    PARESIS    OF 
NEUROPATHIC    HEREDITY. 

A  boy  of  neuropathic  heredity,  both  paternal  grand- 
parents having  had  paralytic  troubles,  a  cousin  having 
been  insane  and  his  father  formerly  intemperate.  No 
evidence  of  syphilis.  During  childhood  he  was  healthy 
and  a  good  scholar.  At  14  he  was  put  to  work.  After  a 
month,  his  intelligence  began  to  fail  and  he  had  to  be  told 
everything  that  he  had  to  do ;  he  wrote  badly  and  could 
not  make  arithmetical  calculations  ;  he  seemed  changed, 
taciturn  and  silly ;  he  stammered  at  times  and  his  hands 
trembled  when  tired.  On  admission,  he  had  wet  his  bed 
for  a  month ;  backward  in  physical  development ;  slight 


192  ETIOLOGY. 

evidences  of  puberty  though  17.  His  expression  was  dull, 
walk  clumsy,  all  movements  awkward.  His  mind  was 
much  enfeebled,  he  seemed  apathetic  and  indifferent. 
Memory  poor,  no  delusions ;  tremor  of  tongue  and  lips, 
extending  at  times  to  other  facial  muscles ;  articulation 
imperfect,  especially  when  tired  and  with  the  lingual 
consonants  ;  tremulous  hands,  clumsiness  of  handwriting 
with  tendency  to  omit  and  misplace  ;  inequality  of  pupils; 
attacks  of  formication,  beginning  in  right  foot  and  involv- 
ing the  whole  right  side ;  headache,  general  muscular 
weakness,  no  localized  paralysis,  knee-jerks  exaggerated. 
(Abstract,  Charcot,  Archiv  de  Neurologie,  March,  1892, 
vide  American  Journal  of  Insanity,  Vol.  49,  p.  76.) 

GENERAL    PARESIS    IN    MOTHER    AND    CHILD. 

General  paralysis  in  a  child  of  11  and  in  the  mother  at  45. 
There  was  a  neurotic  family  history  and  the  mother  had 
had  syphilis.  One  younger  child  died  at  an  early  age  of 
convulsions,  said  to  have  been  caused  by  congenital  syphi- 
lis. The  mental  affection  first  was  present  in  the  daughter, 
who,  up  to  the  age  of  10  or  12,  was  a  very  promising  girl. 
The  first  symptoms  were  those  of  inability  to  skate  as 
well  as  usual.  The  writing  soon  became  affected  and  her 
dullness  gradually  increased  to  helpless  dementia.  The 
mother  began  to  be  affected  a  few  years  later  than  the 
daughter.  The  first  symptom  was  extreme  jealousy. 
Later  she  became  very  indolent  and  careless  of  her  per- 
son, she  began  to  drink  freely  and  was  unmindful  of  her 
household  duties.  Paresis  of  the  muscles  of  articulation 
was  an  early  symptom  and  the  disease  progressed  in  typi- 
cal fashion.  (Abstract,  Muller,  Allgemeine  Zeitschrift  fiir 
Psychologic,  55,  98,  p.  151.) 

GENERAL    PARESIS   IN    CHILD    AND    TABES   IN    MOTHER. 

The  father  was  alcoholic  and  infected  the  mother  with 
what  was  apparenll}-  syphilis,  three  or  four  years  before 
the  birth  of  the  child.  When  aged  forty- four  the  mother 
developed  tabes  and  at  the  age  of  seven,  following  a  severe 
attack  of  scarlatina  with  nephritis,  the  child  showed  signs 


SYPHILIS.  193 

of  beginning  dementia.  Her  disposition  changed  and  she 
developed  a  general  tine  tremor.  Later  she  had  an  epi- 
leptiform attack  and  subsequently  developed  typical  gene- 
ral paresis.  (Abstract,  Grannelli,  Rivista,  Psich.  Neuro- 
pat.,  2,  98,  p.  213.) 

Syphilis.  —  In  the  estimation  of  many  authorities 
syphilis  is  regarded  as  the  most  common  cause  of 
general  paresis.  Bonnet  and  Anglade  have  held 
that  in  seventy  to  ninety  cases  out  of  a  hundred  in 
general  paresis  syphilis  has  existed.  Bannister  gives 
the  percentage  as  89,  Houghberg,  75.7;  Mendel,  75; 
Berkley,  50,  and  Graf,  40  per  cent.  According  to 
Kraepelin  the  subjects  of  S3^philis  are  from  sixteen 
to  seventeen  times  more  liable  to  general  paresis 
than  others  not  so  affected. 

The  tendency  of  the  age  is  to  regard  the  cases 
of  general  paresis  where  syphilis  has  existed  as 
a  parasyphilitic  disorder.  The  exact  relationship 
between  syphilis  and  general  paresis  has  not  been 
solved,  although  it  has  been  under  active  discussion 
for  a  long  time.  Mickle  quotes  the  statistics  of 
Lewin  in  which,  out  of  20,000  cases  of  syphilis,  only 
one  per  cent,  became  insane  and  not  one  case  of  gen- 
eral paresis  developed.  The  pathological  processes 
of  syphilitic  brain  disease  and  general  paresis  are  dif- 
ferent. In  syphilis  there  are  changes  in  the  blood- 
vessels, and  the  formation  of  gummata,  or  diffuse 
meningeal  infiltration.  The  first  and  third  occur 
about  the  base  of  the  brain,  while  the  second  is  more 
apt  to  appear  in  the  cortical  region.  On  the  other 
hand,  in  general  paresis  there  is  a  chronic  meningitis 
of  the  convexity  with  atrophy  of  the  cortex.  Some 
years  ago  Peterson  made  a  study  of  syphilis  as  an 
etiological  factor  of  paresis,  which  comprised  an  ex- 
amination of  the  contributions  of  no  fewer  than 
seventy  authors  and  his  conclusions  in  this   connec- 


194  ETIOLOGY. 

tion  are  interesting,  (i)  A  history  ol  syphilis  is 
found  in  sixty  to  seventy  per  cent,  of  cases  of  general 
paralysis  of  the  insane.  (2)  The  fact  must  not  be 
lost  sight  of  that  in  thirty  to  forty  per  cent,  of  these 
cases  no  history  of  syphilis,  congenital  or  acquired,  is 
to  be  found.  (3)  Antecedent  syphilis  is  seven  to 
ten  times  more  frequent  in  general  paralysis  than  in 
other  forms  of  insanity.  (4)  Syphilis  is,  therefore, 
to  be  looked  upon  as  a  frequent,  but  not  constant,  fac- 
tor in  its  production.  (5)  But  paralytic  dementia  is 
not  a  form  of  specilic  disease,  not  a  late  syphilitic 
manifestation,  nor  is  it  a  form  of  degeneration  de- 
pending upon  the  syphilitic  poison  for  its  origin. 
(6)  The  relationship  of  syphilis  to  general  paresis 
lies  in  the  facts  that  it  is  a  widespread  disorder  in  all 
communities,  that  it  weakens  the  constitution  and 
vitiates  the  blood  in  many  in  whom  it  infects,  and 
that  the  system  is  thus  prepared  in  many  cases  for 
the  direct  operation  of  the  final  etiological  factors  of 
general  paresis,  viz.,  alcoholism,  excessive  venery, 
heredity  and   mental  overstrain  and  excitement. 

The  failure  of  syphilitic  remedies  to  arrest  the 
course  of  general  paresis  even  when  there  is  a  his- 
tor}'  of  syphilis  preceding  is  further  evidence  of  the 
difterence  of  the  processes.  The  two  prominent  sup- 
positions current,  explaining  the  mode  of  infection  in 
syphilitic  cases,  are:  (i)  That  the  paresis  is  not  due 
to  the  direct  action  of  the  syphilitic  virus  but  that  it  is 
caused  by  a  parasyphilitic  poison  the  result  of  some 
remote  nutritional  or  tissue  changes,  initiated  by 
syphilis.  (Fournier.)  (2)  That  the  cerebral  tissues, 
profoundly  exhausted  b}'  the  infection  of  syphilis,  are 
less  resistant  to  the  influences  of  ordinary  causes. 
"  It  is  significant,"  says  Dercum,  "  that,  for  the  most 
part,  paresis  in  syphilitic  subjects  is  a  late  develop- 
ment.    In  Houghberg's  cases,  eighty-one  in  number, 


SYPHILIS.  195 

the   onset  occurred   in   from  five   to   nineteen   years 
after  infection." 

GENERAL    PARESIS    FROM    SYPHILIS    BEFORE    MARRIAGE. 
WIFE    INFECTED. 

William  B.  J.;  married;  set.  36;  photographer;  no 
neurotic  history;  first  attack.  He  contracted  syphilis 
before  marriage ;  he  had  but  slight  secondary  symptoms 
and  married  two  years  later.  His  wife  had  no  children 
but  developed  secondary  syphilis  and  has  for  years  been 
a  martyr  to  all  sorts  of  troubles  due  to  this  source.  She 
now  has  syphilitic  laryngitis.  The  patient  has  had  no 
cranial  nerve  paralysis  but  has  been  greatly  distressed 
by  his  wife's  sufferings  and  also  by  business  worries. 
Eighteen  months  before  admission,  he  began  to  lose  his 
memory ;  four  months  before  admission,  he  had  severe 
headaches;  hallucinations  of  sight;  right  pupil  large;  walk 
feeble,  tottering  ;  knee  reflexes  brisk.  On  admission,  he 
showed  confusion  and  a  weak  mind ;  restless  and  inco- 
herent ;  pupils  unequal ;  skin  greasy ;  labial  tremors  and 
twitchings  ;  great  physical  weakness  ;  loss  of  vesical  con- 
trol;  exaltation;  optic  discs  hazy,  probably  due  to  old 
syphilitic  retinitis.  He  had  cystitis  and  once  hemorrhage 
from  the  urethra  and  hematoma  in  right  ear.  Discharged 
uncured  after  a  year.  (Abstract,  Savage,  Transactions 
Ninth  International  Medical  Congress,  Vol.  5,  p.  409.) 

GENERAL    PARESIS    DUE    TO    CONGENITAL    SYPHILIS. 

J.  B.,  aef.  18,  paternal  grandfather  died  in  asylum; 
patient's  father  had  been  a  "show  case"  of  syphilis  and 
he  is  now  convalescing  from  an  attack  of  hemiplegia  and 
is  pathologically  exalted  on  every  point,  especially  on  his 
syphilis.  The  patient,  as  a  small  and  sickly  infant,  had 
convulsions  a  few  hours  after  birth,  but  had  good  health 
till  fourteen ;  active,  intelligent,  with  considerable  musical 
talent.  When  sixteen  years  old  he  had  convulsions  for  two 
days,  followed  by  slight  mental  deterioration.  At  sixteen, 
fits  returned  producing  more  marked  mental  change, 
insomnia,  change  of  temper  and  loss  of  memory.     Nine 


196  ETIOLOGY. 

months  before  admission  he  had  four  very  severe  epilepti- 
form seizures,  and  two  months  later  he  had  one  tit  which 
left  him  ''paralyzed."  He  has  had  several  further  attacks 
during  the  six  months  before  admission.  On  admission, 
physiognomy  characteristic  of  congenital  syphilis ;  head 
small  and  misshapen,  with  other  signs.  His  pupils  were 
irregular  and  unequal,  responding  sluggishly  to  accom- 
modation and  light  and  very  slightly  to  the  sympathetic 
reflex.  There  is  general  tremor  and  twitching  of  facial 
muscles,  plantar,  knee-jerk  and  cremasteric  reflexes  very 
exaggerated  and  ankle  clonus  well  marked ;  gait  is  un- 
certain, hasty  and  tottering.  There  is  general  cutaneous 
hyperesthesia;  tongue  movements  jerky,  and  its  extrinsic 
muscles  tremulous  ;  speech  characteristic  of  general  par- 
esis. Patient  smiles  and  grimaces.  It  is  diflicult  to  arrest 
his  attention,  as  he  is  busily  engaged  in  gathering  up  and 
secreting  any  rubbish  that  is  about ;  he  shows  marked 
dementia.  He  can  tell  his  name  but  almost  nothing  else. 
He  says  he  is  "very  happy"  and  in  a  silh^  way  spars 
with  those  about  him,  but  a  moment  later  he  cringes  as  in 
fear  and  whimpers  like  a  beaten  cur.  Two  months  after 
admission  he  had  a  slight  epileptiform  seizure,  followed 
by  paresis  of  right  side,  and  spastic  rigidity  of  right  side ; 
control  over  rectum  and  bladder  lost;  pupils  widely 
dilated,  unequal  and  sluggish  to  light.  A  few  hours 
later,  decubitus  acutus  formed  over  sacrum.  He  was 
unable  to  answer  questions  or  comprehend  directions ; 
very  w-eak,  temperature  100.6°,  pulse  90.  Mentally  apa- 
thetic. Two  days  later  general  spastic  rigidity,  marked 
twitching  of  all  muscles,  most  pronounced  on  vastus  ex- 
ternus  ;  increased  hyperesthesia  over  spine,  temperature 
102°,  pulse  97.  Next  day,  November  4th,  rigors,  deep 
flush  on  cheek,  cardiac  action  feeble  and  excited,  pulse 
no,  temperature  104°.  He  grinds  teeth  and  makes  masti- 
catory efforts.  November  5th,  pupils  regular  and  brisker 
reaction.  Increase  of  patellar  and  cremasteric  reflexes, 
temperature  100°,  pulse  90.  November  12th,  slight  im- 
provement, temperature  between  100°  and  101°,  pulse 
about  90  ;    he  is  excited  and  destructive.     November  17th, 


SYPHILIS.  197 

several  petechial  spots  appeared  on  chest,  arms  and  legs 
and  large  purpuric  extravasations  over  buttocks  and  abdo- 
men. He  became  very  prostrate,  refused  food  and  medi- 
cine, and  gradually  collapsed;  temperature  falling  to  97° 
on  the  20th.  He  died  on  the  21st,  death  being  preceded 
by  slight  convulsive  seizures.  (Abstract,  Norman,  Journal 
of  Mental  Science,  Vol.  39,  p.  218.) 

A    CASE    OF  JUVENILE    GENERAL    PARESIS    OF    HEREDITARY 
SYPHILITIC    ORIGIN    WITH    SPECIFIC   VASCULAR    CHANGES. 

A  young  man,  who  died  aged  21,  had  been  healthy  and 
had  shown  normal  intelligence  until  his  fifteenth  year.  At 
this  time  he  had  cramps  and  twitchings,  apparently  epi- 
leptic in  nature  and  with  a  distinct  aura.  His  intelligence 
rapidly  diminished,  speech  became  imperfect  and  vision 
failed.  The  pupils  were  dilated  and  unresponsive,  knee- 
reflexes  exaggerated,  and  there  was  some  spasticity  of  the 
muscles.  The  patient  w'as  completely  demented  and  could 
recognize  no  one  except  his  mother.  His  father  was  svph- 
ilitic,  a  drunkard  and  a  paranoiac.  (Abstract,  Von  Rad, 
Philadelphia  Medical  Journal,  Vol.  i,  p.  634.) 

A    CASE    OF    GENERAL    PARESIS    OF    SYPHILITIC    ORIGIN. 

A  man,  who  had  contracted  syphilis  seventeen  years 
before  and  had  been  under  careful  medical  treatment, 
recovered  and  was  considered  fit  to  marry.  He  married 
and  lived  a  perfectl}'  healthy  life,  free  from  worry  or 
anxiety.  But,  when  onl}-  a  little  over  forty,  he  began  to 
consider  himself  an  old  man.  His  writing  was  not  so  good 
as  formerl}^  His  memory  failed  and  his  energy  and  will 
power  were  wanting.  A  leading  physician  found,  how- 
ever, no  signs  of  danger ;  but  within  a  fortnight  there 
were  marked  symptoms  of  acute  general  paralysis.  (Ab- 
stract, Savage,  of.  cit.,  Vol.  5,  p.  394.) 

A    CASE    OF    GENERAL    PARESIS    IN    FEMALE    WITH    HISTORY 
OF    SYPHILIS. 

I.  M.,  «t.  32,  insane  two  weeks,  and  died  in  one  year 
from  that  time.      She  has  had  several  miscarriages  and  the 

17 


198  ETIOLOGY. 

children  living,  as  well  as  the  patient,  show  signs  of  syph- 
ilis ;  the  husband's  history  condrms  this  conclusion.  She 
had  melancholic  excitement  for  a  short  time  during  lacta- 
tion ;  threatened  to  poison  herself,  to  throw  herself  out  of 
the  window  and  kill  her  children  ;  she  had  a  strong  animus 
towards  her  husband  and  entertained  delusions  regarding 
his  relations  with  the  nurses.  In  a  few  weeks  she  became 
quite  demented,  restless  and  destructive,  tearing  clothing, 
bed  clothes,  etc.  Her  speech  became  paralyzed,-  pupils 
unequal,  which  did  not  respond  readily  to  light.  In  the 
eighth  month  of  her  disease  she  had  an  attack  of  hemi- 
plegia, then  became  bed-ridden  and  at  last  sank  rapidly 
and  died.  (Abstract,  Campbell  Clark,  Mental  Diseases, 
p.  220.) 

A  CASE   OF    GENERAL   PARESIS   OF  SYPHILITIC  ORIGIN  WITH 
A    REMISSION    AFTER    ANTISYPHILITIC    TREATMENT. 

Case  of  a  gentleman  who  had  been  treated  in  the  best 
possible  way  for  the  primary  sore  and  subsequent  stages 
of  syphilis.  About  two  and  a  half  years  after  he  was  sup- 
posed to  be  cured  of  syphilis  he  had  a  very  severe  hemi- 
crania  for  which  he  went  south  without  benefit.  When  he 
returned,  in  addition  to  hemicrania,  he  had  the  usual  initial 
symptoms  of  general  paralysis.  Under  large  doses  of 
potassic  iodid  he  apparently  made  a  complete  recovery, 
returned  to  his  previous  occupation  and  worked  as  well  as 
ever.  A  few  years  later  the  writer  found  that  the  symp- 
toms had  nevertheless  made  regular  progress,  and  he  had 
no  doubt  as  to  what  the  result  would  be.  (Abstract,  Fol- 
som, /or.  c/L,  p.  26.) 

A    CASE    OF    GENERAL    PARESIS    FROM    ACQUIRED    SYPHILIS. 

A.  B.,  xi.  41,  van  driver,  no  hereditar}-  history  of  in- 
sanity, married  twentj'-five  3'ears,  industrious,  of  anxious 
temperament,  moderate  sexual  appetite,  remarkably  tem- 
perate. Six  3'ears  ago  he  contracted  syphilis  and  gave  it  to 
his  wife.  All  active  sj^mptoms  of  it  disappeared  three 
years  ago.  Thirteen  months  prior  to  admission,  his  wife 
noticed  that  he  could  no  longer  perceive  any  odor  and  he 


SYPHILIS.  199 

became  sleepless,  dull  and  very  forgetful.  Later  com- 
plained of  a  fixed  pain  in  the  right  antero-lateral  cephalic 
region,  which  increased  until  it  invaded  the  whole  right 
side  of  the  cranium  and  was  extremely  severe,  especially 
at  night.  Apathy,  insomnia  and  amnesia  increased  daily 
and  taste  hallucinations  became  prominent.  His  action 
became  purposeless,  movements  uncertain,  general  tremor 
set  in,  he  began  to  lose  sexual  power  and  desire,  which 
latter  had  before  been  very  strong.  He  had  distressing 
dreams,  that  he  had  made  a  post-mortem  on  his  wife  and  had 
removed  all  her  viscera  ;  he  became  violent,  threatening  and 
obstinate  ;  and  was  annoyed  and  excited  by  visual  halluci- 
nations. Diagnosis,  syphilitic  tumor  of  brain  with  paretic 
dementia.  On  admission  he  had  cachexia  which  had  re- 
sulted in  advanced  marasmus  ;  gait  tottering,  limbs  ataxic 
in  their  movements,  marked  general  tremor,  fibrillar  twitch- 
ing of  muscles  of  expression,  which  were  also  flattened ; 
patellar,  plantar  and  cremasteric  reflexes  exaggerated, 
well-marked  ankle  clonus.  Cutaneous  sensibility  much  in- 
creased. Tongue  clammy  and  ataxic,  in  voluntary  move- 
ments tremulous,  indented  and  flabby  when  at  rest;  pupils 
small,  irregular  and  unequal,  sluggish  to  direct  consensual 
and  light  stimuli  and  fixed  to  the  sympathetic  reflex.  The 
movements  for  accommodation  were  spasmodic  and  ill- 
directed ;  pupillary  reaction  being  slow  and  incomplete. 
Absolute  loss  of  smell ;  he  could  not  hold  a  pen  or  button 
his  clothes  ;  respiration  quick  and  shallow,  pulse  small  and 
feeble,  tongue  furred ;  pronunciation  blurred  and  chippy. 
Voice  resembled  a  hoarse  whisper.  His  attitude  was  that 
of  rapt  attention,  gazing  into  space,  with  a  want  of  ex- 
pression ;  he  avoided  conversation,  and  was  very  de- 
spondent— "I  am  done,"  etc.  When  put  to  bed  after  ad- 
mission, he  had  a  slight  epileptiform  convulsion,  during 
which  he  passed  urine  involuntarily.  For  twelve  days 
following,  there  was  rapid  mental  and  physical  deteriora- 
tion. He  sat  all  day  in  one  place,  with  limbs  flexed,  neck 
forward,  gazing  into  the  distance,  and  expression  of  intent 
listening.  It  was  difficult  to  arouse  him  from  this  state  ; 
he  talked  of  imaginary  events.     In  two  weeks,,  on  March 


200  ETIOLOGY. 

12,  he  had  a  violent  epileptiform  seizure,  the  convulsions 
throwing  him  out  of  bed.  Afterwards,  an  increase  of 
dementia  ;  he  could  not  answer  questions  or  fix  his  attention. 
He  lay  in  bed  in  a  state  of  general  flexion ;  rigidity  of 
the  limbs,  tendency  to  bed-sores,  spasmodic  masticatory 
and  swallowing  movements,  constant  grinding  of  the 
teeth ;  reflexes  more  exaggerated,  and  general  hyperes- 
thesia well  marked.  After  a  sinus  on  the  foot,  leading 
down  to  the  bone,  had  healed  (early  April),  he  became 
bright,  answered  questions  readily  and  volunteered  re- 
marks. But  gradually  his  expression  became  more  and 
more  "wiped  out,"  general  and  facial  tremor  increased, 
although  on  April  26  he  spoke  more  intelligently  than 
usual.  Control  over  bladder  was  impaired.  On  April  30 
he  had  slight  but  frequent  epileptiform  seizures  after  which 
expression  was  very  fatuous  ;  he  would  not  speak,  tongue 
protruded  to  right.  On  May  i  and  5  he  had  several  seiz- 
ures and  became  very  weak  ;  he  was  mute,  fearful  and 
emotional.  He  remained  in  this  state  till  8  P.  M.  on  the 
7th,  when  he  was  seized  with  epileptiform  convulsions ; 
left  side  became  rigid,  right  relaxed,  lower  jaw  drawn 
down  and  back,  tongue  directed  to  right,  pupils  dilated 
and  insensible  to  light,  plantar  reflexes  absent,  tempera- 
ture rose  suddenly  from  normal  to  102°,  pulse  80,  con- 
jugate deviation  of  head  and  eyes  to  left  and  he  died  the 
same  night.     (Abstract,  Norman,  loc.  ciL,  p.  221.) 

Temperament. — The  idea  has  gained  recognition 
that  a  temperament  of  general  paresis  exists,  and 
certainly  the  reasons  are  credible.  The  temperament 
most  frequently  found  among  paretics  is  the  intensely 
sanguine.  It  is  found  in  those  who  are  inordinately 
ambitious  for  wealth,  fame  or  station,  who  lack  self- 
control  and  are  prone  to  excesses,  who  are  restless 
and  changeable  in  disposition;  also  among  the  fiery, 
choleric,  and  those  with  an  obstinate  disposition. 
Naturally  these  conditions  tend  to  nerve  irritation 
and  exhaustion. 


SEX.  20I 

This  extreme  selfishness  and  lamentable  lack  of  self- 
control,  permitted  to  dominate  a  life,  sometimes  reaps 
in  this  disease  a  very  natural,  but  most  pitiful  harvest. 

PARESIS    IN    TWO    INSTANCES    ATTACKING    BROTHERS. 

Twin  brothers  had  general  paralysis,  the  disease  be- 
ginning and  running  its  course  in  one  sooner  than  in  the 
other.  The  two  had  Hved  in  different  parts  of  the  kingdom 
and  had  no  symptoms  of  syphihs  or  history  of  that  disease. 

Two  other  brothers  at  the  same  age,  32,  became  general 
paretics,  though  they  had  led  utterly  different  hves,  one 
being  sober  and  industrious  while  the  other  was  intemper- 
ate and  licentious.  They  had  inherited  a  tendency  to 
break  down  prematurely  along  the  nervous  lines.  (Ab- 
stract, Savage,  loc.  cit.,  Vol.  5,  p.  393.) 

Sex. — Statistics  uniformly  agree  in  showing  that 
general  paresis  occurs  more  frequently  among  men 
than  women. 

An  interesting  table  by  Regis,^  made  up  from  7,552 
insane  and  868  general  paretics,  gives  the  following 
data:  (i)  In  rural  populations  the  disease  is  about 
one  and  a  half  times  more  common  in  men,  and  rare 
in  either  sex.  (2)  Among  laboring  classes  of  large 
cities  it  is  three  times  more  coinmon  in  men  and  it  is 
relatively  frequent  in  both.  (3)  In  the  higher  classes 
it  is  nearly  thirteen  times  more  frequent  in  men,  and 
very  common  among  men  and  rare  among  women. 
The  number  of  paretics  in  proportion  to  the  whole 
number  of  the  insane  is  estimated  by  the  same  author 
as  follows:  {^a)  Among  men,  3  :  100,  and  among 
women  2.13  :  100.  [b)  In  working  classes  of  large 
cities,  men,  23  :  100,  women,  7.7  :  100.  In  higher 
classes,  men,  33.3  :  100;  women,  2.58  :  100. 

The  ratio  of  liability,  according  to  Sankey,^  is: 
(i)   Males  of  the  lower  class;   (2)   males  of  the  upper 

1  Mental  Maladies,  p.  457. 
''■Ibidem,  p.  283. 


202  ETIOLOGY. 

class;  (3)  females  of  the  lower  class,  and  (4) 
females  of  the  upper  class.  There  is  a  question  as 
to  whether  males  of  the  upper  or  lower  class  pre- 
dominate, some  authors  reverse  the  order  as  given 
above. 

GENERAL    PARESIS    IN    A    YOUNG    WOMAN. 

Marjory  C,  admitted,  aet.  18,  was  the  third  of  a  family 
of  seven.  The  two  eldest  are  living  and  healthy,  the  third 
was  the  patient,  the  fourth  was  still-born,  the  lifth  is  alive 
and  well.  The  two  youngest  were  twins,  one  of  tliem  died 
soon  after  birth  with  convulsions  ;  father  was  intemperate 
but  denied  syphilis.  The  patient's  illness  commenced  four 
years  before  admission,  as  the  result  of  a  severe  fall  on  the 
head.  When  picked  up  she  was  unconscious  and  blood  was 
oozing  from  left  ear,  pus  subsequently  came  out.  Three 
days  after  the  fall  she  suddenly  became  aphasic,  left  side 
of  face  twitched  ;  she  did  not  lose  consciousness,  and  the 
attack  passed  off  in  ten  minutes.  She  remained  well  for 
three  years.  A  year  before  admission,  her  manner  and 
mental  capacity  began  to  change.  She  could  not  keep  her 
situation  as  a  servant ;  she  would  pick  up  and  eat  crumbs 
of  bread  on  the  street,  and  could  give  no  reason  for  doing 
so.  Two  months  before  admission  she  fell  and  was  picked 
up  unconscious,  although  the  fall  was  not  at  all  severe. 
She  soon  recovered  consciousness  and  then  it  was  noticed 
that  her  mouth  was  drawn  to  the  left.  She  developed 
delusions  ;  she  thought  she  was  the  mother  of  a  large  family  ; 
she  became  suspicious  of  her  relatives.  When  admitted  the 
disease  was  well  advanced.  She  walked  with  difficulty, 
muscular  power  much  impaired  ;  she  was  very  deficient 
mentally  ;  she  seldom  spoke  or  comprehended  simple  ques- 
tions :  memory  not  very  good,  especially  for  recent  events, 
but  she  knew  simple  multiplication  table  ;  she  was  rather 
depressed  in  appearance.  Tongue  and  lips  tremulous, 
voice  quavering,  pupils  unequal,  did  not  react  well  to 
light  and  not  at  all  to  accommodation ;  knee-jerks  and 
superficial  reflexes  slightly  increased.  She  is  undersized 
and  undeveloped,   and   had  never  menstruated ;    no  very 


SEX.  203 

evident  marks  of  syphilis.  After  admission,  disease  pro- 
gressed rapidly,  she  became  more  mentally  deficient,  spoke 
less,  until  she  finally  ceased  to  speak  ;  she  became  so  weak 
that  she  was  confined  to  bed.  She  lost  flesh  in  spite  of 
extra  feeding ;  she  had  most  careful  nursing  but  died  of 
exhaustion  three  months  after  her  admission.  (Abstract, 
Middlemass,  Journal  of  Mental  Science,  Vol.  40,  p.  38.) 

GENERAL     PARESIS    IN    WOMAN.       CAUSE    SHOCK.       DIED    IN 
THIRTY-THREE    MONTHS. 

M.  E.  J.,  admitted  in  June;  female;  single;  ast.  35; 
servant.  She  had  a  child  when  19.  Three  weeks  after 
Christmas  she  was  disappointed  in  marriage,  became 
altered  in  behavior,  at  first  was  depressed  and  would  cry 
for  hours  together,  soon  after  began  to  talk  nonsense,  said 
she  was  going  to  Paris,  talked  much  of  her  lover  who  had 
just  married  another ;  her  mother  kept  her  at  home  two 
months,  when  she  became  destructive  and  violent;  she 
was  then  taken  to  the  workhouse.  On  admission,  mind 
appeared  imbecile,  she  is  noisy  and  violent  at  times,  fairly 
nourished,  gait  tottering,  articulation  confused,  says  she 
has  plenty  of  money,  industriously  inclined,  offers  to  assist 
nurses.  Tenth  month,  she  has  gained  flesh.  Symptoms  of 
general  paresis  well  marked,  especially  as  regards  articu- 
lation ;  at  times  excited,  at  times  cries  and  roars  lustily. 
Fourteenth  month,  motor  paresis  much  increased,  unable 
to  stand,  falls  about,  wet  and  dirty.  Seventeenth  month, 
articulation  worse,  is  scarcely  intelligible  ;  she  is  confined 
to  bed,  muttering  :  you  must  have  a  million  million  cows 
to  suck,  thousands  of  dolls,  beautiful  cows — but  she  is 
stronger,  pupils  equal.  Eighteenth  month,  able  to  leave 
bed,  restless,  would  not  remain  in  bed,  she  takes  nourish- 
ment well.  Nineteenth  month,  she  is  up  and  roaming 
about  ward  but  gait  unsteady.  Twentieth  month,  excited, 
she  tried  to  strike,  articulation  very  indistinct,  she  dressed 
up  a  foot  stool  and  carried  it  about  as  a  doll.  Twenty-first 
month,  mind  very  imbecile,  she  is  regardless  of  decency. 
Twenty-second  month,  paretic  symptoms  continue  with 
restlessness,  she  wanders  about  and  shows  a  disposition  to 


204  ETIOLOGY. 

violence.  Twenty-sixth  month,  she  is  still  able  to  be  up, 
mind  demented,  gait  unsteady,  voice  tremulous,  pupils 
equal ;  she  is  stronger  than  a  month  ago.  Twenty-seventh 
month,  she  is  stouter  and  well  nourished,  scarcely  able  to 
speak,  still  up  and  restless.  Thirtieth  month,  general  pow- 
ers failing,  speech  ver}'  drawling,  imbecile  laugh,  says  she 
has  a  beautiful  fortune  left  her,  stuffs  her  mouth  with  food 
in  eating,  some  difficulty  in  swallowing.  Thirty-third 
month,  pupils  equal,  she  is  unable  to  stand,  lies  in  bed 
with  knees  up,  difficult  swallowing,  grinding  of  the  teeth, 
mind  very  demented,  legs  gradually  more  drawn  up;  she 
died  from  exhaustion  without  convulsions  in  the  thirty- 
fourth  month  of  the  disease.  (Abstract,  Sankey,  op.  cit., 
p.  321.) 

PARESIS    IN    DISSOLUTE    WOMEN. 

Among  unmarried  women,  prostitutes  seem  particularly 
liable  to  paresis,  a  fact  noted  by  Snell  and  Cullerre,  who 
found  eighteen  of  this  class  out  of  thirty-nine  female  par- 
etics. Of  the  three  unmarried  women  paretics  I  have 
known,  one  was,  I  believe,  of  this  class,  and  one  of  the 
others  had  been  an  unlegalized  mother.  (Abstract,  Ban- 
nister, American  Journal  of  Insanity,  Vol.  50,  p.  483.) 

A    CASE    OF   GENERAL    PARESIS    IN   A   GIRL.       MOTHER   ALSO 
HAD    PARESIS. 

A  girl,  ait.  14,  suffered  with  general  paresis.  The 
mother  and  paternal  grandmother  both  died  in  asylums. 
The  mother  was  a  general  paralytic.  There  was  no 
S3'philis.  The  patient  had  been  healthy  until  at  six  when 
she  became  restless  and  very  destructive.  Her  mental 
state  was  one  of  complete  dementia  and  she  died  when 
fifteen.  (Abstract,  Marr,  Philadelphia  Medical  Journal, 
Vol.  4,  p.  704.) 

Age. — General  paresis  is  a  disease  of  middle  life, 
much  more  common  between  the  ages  of  thirty-live 
and  fifty  years  than  at  an  earlier  or  later  period.  It 
attacks  men  in  the  prime  of  life,  when  the  brain  and 
nervous  system  are  in  the  highest  condition  of  func- 


AGE.  20^ 

tional  activity  and  at  an  age  when  the  most  severe 
strains  have  to  be  borne.  In  later  years  the  fortune 
is  made,  or  the  business  life,  with  its  pressing  duties 
has  grown  familiar  and  the  early  anxieties  and  cares 
have  been  relieved. 

The  disease  is  very  infrequent  before  twenty  years 
of  age  and  is  unknown  after  the  age  of  seventy-six. 
Its  occurrence  between  nine  and  twenty  years  of  age 
has  been  occasionally  reported  but  the  disease  is  then 
usually  luetic  in  nature  and  runs  its  course  quickly. 
At  twenty-five  it  is  infrequent,  but  the  common  age 
of  occurrence  is  between  thirty  and  forty.  After 
fifty-five  it  is  rare,  but  it  has  been  known  to  follow  late 
acquired  syphilis  and  thus  has  been  found  in  a  few 
recorded  instances  in  men  between  sixty  and  seventy- 
five  years  of  age.  Hirschl,  for  example,  gives  the 
case  of  a  man  who  contracted  syphilis  in  his  fifty- 
sixth  year  and  the  symptoms  of  paresis  began  at 
sixty.  The  greatest  number  of  cases  shown  in  the 
early  tables  occur  between  the  fortieth  and  fiftieth 
years,  but  late  statistics  show  the  greatest  number  to 
occur  between  thirty  and  forty  years  of  age. 

This  reduction  of  the  limit  of  the  age  of  development 
of  the  disease  has  occurred  within  recent  vears  and  is 
due  to  the  strain  of  modern  life.  The  same  condition 
exists,  especially  in  the  cities  of  all  countries,  where 
there  is  excitement  and  mental  strain  in  business  life. 
Mickle,  in  speaking  of  this  feature  of  the  disease  in 
Europe,  says :  "  The  lowering  of  the  average  age 
speaks  ill  for  the  vitality  of  Western  Europe,  in  as 
much  as  general  paresis  is  the  result  of  exaggerated 
expense  of  vital  force  and  premature  senility." 

The  cases  found  in  early  life  are  infrequent  but 
occasional,  and  are  called  sometimes  "  developmental 
general  paresis."  For  details  see  section  under  par- 
ticular symptomatology. 


2o6  ETIOLOGY. 

Among  women  the  disease  is  much  less  common, 
as  stated  more  fully  elsewhere,  develops  from  three 
to  five  years  earlier,  and  runs  its  course  more  mildly, 
requiring  greater  length  of  time. 

A    CASK    OF    GENERAL    PARESIS    IN    AN    OLD    MAN. 

S.  B.,  £et.  6i,  but  looking  70,  married,  an  artist,  no  in- 
sane relatives,  no  previous  attack  of  insanity.  Present  one 
dates  back  six  months,  due  to  pecuniary  losses,  showing 
itself  with  forgetfulness  of  small  things.  He  became  inco- 
herent and  childish,  lost  himself  in  his  own  house  ;  mistak- 
ing his  relatives ;  neglecting  the  decencies  of  society ; 
restless,  fidgety,  and  rubbing  his  head  with  his  hands. 
On  admission  he  had  tremulousness  of  lips  and  tongue, 
with  hesitation  of  speech  ;  he  became  more  restless  and  in- 
terfering and  lost  mental  power.  A  month  after  admission 
he  had  a  series  of  convulsive  seizures  from  which  he  re- 
covered, but  was  left  weaker  in  mind  ;  at  the  end  of  three 
months  he  had  a  further  series  of  fits  and  again  recovered. 
Mental  and  physical  weakness  increased  and  he  died ; 
pachymeningitis  was  found  post  mortem.  These  cases  are 
often  difficult  to  differentiate  from  those  of  senile  dementia. 
(Abstract,  Savage,  of.  cit.,  p.  311.) 

GENERAL    PARESIS    IN    A    MAN    SEVENTY-FIVE    YEARS    OLD. 

Mr.  Y.,  £et.  75  ;  four  children  ;  a  retired  merchant,  gave 
up  business  five  years  ago.  He  had  become  erratic,  had 
grown  unusual  and  peculiar ;  he  had  had  for  some  years 
"  nervous  dyspepsia."  His  mental  vigor,  how^ever,  seemed 
to  increase.  He  became  interested  in  social  reform  and 
took  up  hobbies  which  he  rode  for  a  while  and  then 
dropped ;  horses,  dogs,  poultry,  etc.  After  the  novelty 
had  worn  off,  he  would  forget  his  fads  entirely.  He  had 
attacks  of  depression,  with  tendency  to  seclude  himself 
and  to  lose  consciousness  of  his  surroundings.  Two 
weeks  before  admission  he  was  more  excited  and  erratic, 
trying  to  carry  out  absurd  schemes  and  being  violent 
when    opposed.     On    admission,   his    physical    condition 


AGE.  207 

was  excellent.  Pupils  contracted  and  immobile ;  tongue 
slightly  tremulous,  but  not  facial  muscles;  patellar  reflex 
exaggerated  ;  he  was  constantly  moving  about  and  talking 
about  his  plans.  He  had  grandiose  delusions  about  himself 
and  his  wealth.  He  was  dictatorial,  easily  angered,  and 
would  not  brook  opposition  ;  appetite  good  and  bowels  reg- 
ular; he  slept  well  at  night;  during  the  lirst  three  days  re- 
sented restraint  and  sent  telegrams  for  aid  to  many  promi- 
nent people.  He  attacked  his  attendant  frequently;  and 
insisted  that  every  one  should  obey  because  he  was  such  a 
great  man.  The  next  day  he  said  he  had  the  greatest 
intellect  in  the  world,  could  acquire  any  language  in  three 
weeks,  no  one  could  compare  with  him,  etc.  Three  days 
later  he  was  quieter  and  disclaimed  all  ill-feeling  towards 
others.  He  was  full  of  schemes  for  the  material  advance- 
ment of  his  friends  in  the  ward ;  said  he  had  been  put  in 
the  institution  bv  mistake  and  that  his  friends  didn't  know 
where  he  was.  He  addressed  the  envelope  of  a  letter  to 
"  Mrs.  R.  two,  three  to  fifty  without  the  five;  living  there 
a  long  time,  but  the  cry  is  coming,  push  along,  better 
hearken,  it  is  a  loud  cry  especially  in  New  York."  His 
pupils  were  very  contracted  and  did  not  react  to  light ; 
marked  tremor  of  tongue ;  no  difficulty  in  articulation ; 
marked  arteriosclerosis ;  pulse  90  and  incompressible. 
Said  he  was  worth  ten  thousand  millions  and  would  buy  the 
institution  and  make  it  a  home  for  little  girls  from  the 
city.  His  memory  failed  rapidly  ;  appetite  good  :  says  he 
is  very  strong;  the  management  of  large  affairs  is  noth- 
ing to  him,  etc.  All  his  delusions  were  becoming  more 
expansive.  In  a  letter,  he  says:  "In  a  recent  invest- 
ment, I  have  made  a  great  deal  of  money ;  I  was  rich 
before  and  will  soon  be  embarrassed  with  riches.  I  have 
bought  Mrs.  S.'s  house  just  as  it  is,  beautifull}'  furnished 
for  you  and  Mr.  C.  and  would  like  to  have  you  come 
here  and  live  as  long  as  you  live,  in  the  greatest  plenty. 
Mr.  C.  will  not  have  to  work  at  all  except  for  his  pleasure. 
You  will  have  your  carriages  and  horses  and  everj'thing 
like  a  rich  woman.  I  have  bought  all  the  houses  in  Irish- 
town,  cheap  as  dirt,  but  I  will  tear  them  down  and  have 


2o8  ETIOLOGY. 

rows  of  fine  stores  put  up  in  their  place.  I  send  you  $50 
to-day  and  will  send  you  plenty  more  soon.  Oh,  if  I 
ain't  a  happy  man  I  Come  quickly,  I  have  all  the  money 
you  will  ever  need.  You  can  have  miles  of  hot-houses 
and  millions  of  roses  and  chrj^santhemums,"  Two  weeks 
later,  he  was  so  rapt  up  in  his  ideas  that  he  rarely  spoke  to 
any  one ;  sometimes  he  did  not  eat.  He  thinks  his  food  is 
prepared  by  a  French  cook  and  he  constantly  magnifies 
the  quality  of  his  food ;  his  possessions  include  all  of 
England  and  Ireland.  He  has  risen  to  the  formation  of  a 
new  government  and  a  reorganization  of  society.  Finally 
he  came  to  own  Africa  and  then  the  world.  The  next 
month,  his  physical  strength  failed  and  he  became  more 
excited.  His  memory  was  gone  and  he  was  completely 
self-absorbed.  He  said:  "I  am  God,"  "I  am  the  Law," 
"Everything  is  according  to  my  will."  "Announce  to 
the  world  that  a  new  world  has  emerged  from  its  hiding 
place  of  love  and  mercy  to  all  men  and  it  will  enter 
at  once  upon  its  glorious  mission  of  peace  and  good  will 
to  man."  Then  followed  elaborate  plans  for  the  gov- 
ernment and  language  of  the  new  world,  signing  himself : 
"The  Supreme  Ruler  of  the  new  world,  as  of  the  old," 
One  day,  he  was  a  loving,  beneficent  ruler;  the  next,  an 
avenging  deity,  pronouncing  curses  on  every  one  who 
came  near  him.  He  said  "I  am  God  and  no  one  is  fit  to 
talk  with  me."  The  next  day  he  boasted  of  his  muscular 
power  and  wanted  to  spar  with  every  one ;  said  he  was  a 
second  Samson.  Next  came  an  attack  of  depression,  he 
being  much  of  the  time  on  his  knees  communicating  with 
the  deity.  But  he  soon  became  exalted  again ;  tried  to 
take  off  his  clothing,  because  in  the  new  world  no  cloth- 
ing is  allowed.  He  never  spoke  directly  to  any  one  or 
answered  questions.  Sexual  perversion  appeared.  After 
this,  he  was  restless  and  excited  and  he  had  visual  and 
auditory  hallucinations.  Once,  he  tore  his  mattress  to  pieces 
because  the  Empress  of  China  was  sewed  up  in  it.  His 
delusions  became  transient ;  that  everyone  who  came  near 
him  meant  to  kill  him ;  sometimes  talked  of  suicide ; 
thought  he  was  a  great  military  genius,   Napoleon    and 


RACE    AND    SOCIAL    INFLUENCES.  209 

Nelson  combined.  After  this,  he  had  an  attack  of  ex> 
haustion,  with  muttering  delirium,  and  picking  at  the  bed- 
clothes. During  the  next  week,  he  failed  rapidly.  The 
arteriosclerosis  increased.  His  pulse  ran  up  to  120.  He 
occasionally  had  an  involuntary  stool  and  passed  his  urine 
in  bed.  He  thought  his  room  was  haunted  by  dogs  and 
cats  but  he  was  generally  in  ecstasy.  Three  days  before 
death  he  became  stuporose  and  the  day  before  he  died  he 
had  right  hemiplegia,  without  involvement  of  the  facial 
muscles.  (Abstract,  Tomlinson,  Journal  of  Nervous  and 
Mental  Diseases,  Vol.  16,  p.  772.) 

Race  and  Social  Influences. — So  free  are  some  coun- 
tries from  general  paresis  that  for  a  time  it  was  sup- 
posed to  be  confined  to  certain  races,  particularly  to 
the  Anglo-Saxon.  This  was  based  on  the  fact  which 
now  is  well  determined  that  it  is  unknown  in  Asia 
and  to  the  savage  in  his  native  state.  The  disease 
accompanies  the  hurry  and  worry  of  the  extreme 
struggle  for  both  existence  and  high  place  in  late 
civilized  life,  regardless  of  race  or  nation. 

For  example,  the  Scotch  Highlander  is  free  so  long 
as  he  remains  in  his  rural  surroundings,  with  little  to 
fire  his  ambition  or  imagination,  but  when  he  goes 
into  city  life  and  his  energy  and  determination  are 
bent  on  competition,  he  places  himself  in  a  position 
that  may  readily  end  in  his  being  a  paretic.  The 
Irishman,  too,  almost  entirely  free  from  the  disease 
at  home,  is  not  at  all  exempt  from  it  in  American 
cities,  or  in  English  factories  and  mines,  where  in  the 
latter  case,  his  life  is  made  up  of  the  hardest  of  work 
and  the  lowest  and  roughest  of  surroundings. 

It  is  said  the  disease  was  unknown  among  the 
slaves  of  the  Southern  States  and  unreported  among 
free  negroes  until  they  came  to  the  centers  of  popu- 
lation. At  present  in  Baltimore,  as  an  instance,  pare- 
sis claims  the  same  percentage  of  negroes,  according 


2IO  ETIOLOGY. 

to  the  population,  that  it  does  among  Caucasians.  In 
Norway  and  Sweden  the  disease  is  ver}^  rare.  In 
France  and  Germany  it  is  common  among  brain  work- 
ers. In  our  own  country  and  in  England  it  is  found 
most  frequentl}'  in  regions  where  competition  has  been 
strongest  for  several  generations.  In  the  Western 
States  onl}^  one  or  two  per  cent,  or  less,  are  general 
paretics  when  coming  from  farm  life;  but  in  the  East- 
ern States  from  ten  to  sixteen  per  cent,  in  the  populous 
districts.  Berkley  ^  says :  "  It  is  in  the  cities  where 
rum  and  S3philis  dwell  in  close  fellowship,  where  the 
strife  and  excitement  of  modern  civilization  is  ever 
at  flood  tide,  that  general  paresis  is  rife." 

Spitzka,^  from  a  careful  study  of  the  subject  among 
the  indigent  insane  of  New  York  City,  gives  the  pro- 
portion of  general  paretics  as  follows:  Anglo-Saxon, 
13.29;  Celts,  11.58;  Germans,  11. 13;  Hebrews,  10.29; 
Negroes,  8.82.  He  shows  that  the  Anglo-Saxon 
race,  the  one  of  greatest  speculative  business  tend- 
encies and  of  highest  intellectual  development,  has 
the  largest  number;  that  mere  business  exertion  is 
not  the  most  fertile  cause  from  the  low  percentage  of 
the  Hebrew  race;  that  intellectual  exertion,  per  se,  is 
not  a  cause,  as  shown  by  the  lesser  percentage  of  the 
Germans,  who  stand  first  in  the  abstract  and  specu- 
lative sciences;  that  a  libidinous  life  is  not  wholly  re- 
sponsible, for  if  such  a  reflection  were  to  be  cast  on 
any  race  in  this  respect  it  would  be  the  Negro  race, 
which  shows  the  lowest  percentage  of  general  pare- 
sis, and  to  which,  living  in  natural  conditions,  not 
compelled  to  enter  into  competition,  the  disease  is 
unknown.  The  writer  then  adds:  "The  conclusion 
will  seem  reasonable  that  general  paresis  is  more  fre- 
quent with  races  of  a  high  than  of  a  low  cerebral  or- 

'  Mental  Diseases,  p.  194. 
2 Manual  of  Insanity,  p.  iSi. 


PUte  X. 


GENERAL  PARESIS  IN  THE  NEGRO. 


RACE    AND    SOCIAL    INFLUENCES.  211 

ganization,  because  their  higher  civilization  induces 
a  restless  mental  activity  and  its  attendant  emotional 
strain.  General  paresis,  therefore,  is  not  a  penalty 
of  high  cerebral  development,  but  the  expression  of 
a  discrepancy  between  the  instrument  and  its  pur- 
pose; of  the  inadequacy  of  some  brains  to  support 
the  strain  to  which  the  race,  as  a  whole,  is  subjected." 
It  is  generally  agreed  among  alienists  that  the  gen- 
eral conditions  incident  to  the  life  of  the  poor  predis- 
pose them  to  insanity,  and  it  is  found  that  a  higher 
per  cent,  of  these  classes  become  insane  than  those 
of  the  middle  and  higher  classes.  Whether  this  rule 
applies  to  the  distribution  of  general  paresis  is  a 
mooted  question.  Some  authorities,  as  Mickle,  be- 
lieve that  paresis  is  more  prevalent  in  the  lower 
classes,  while  other  observers  of  equal  rank,  for  in- 
stance Regis,  find  that  the  upper  classes  suffer  most 
from  it.  It  appears  from  compiled  statistics  of  the 
insane,  for  a  series  of  recent  years,  comprising  the  in- 
sane of  the  Atlantic  seaboard  in  and  about  the  large 
commercial  centers  of  Boston,  New  York,  Philadel- 
phia and  Baltimore  that  the  highest  per  cent,  of  gen- 
eral paresis  among  men  makes  its  appearance  in  the 
better  classes  of  societ}^  Of  17,633  indigent  male 
patients,  13.7  per  cent,  were  general  paretics,  and  of 
16,956  indigent  female  patients,  1.3  were  general 
paretics;  of  3,005  private  male  patients  the  percent, 
of  general  paretics  was  16.2,  and  of  2,736  private 
female  patients  the  per  cent,  was  .18.  The  result, 
therefore,  may  be  put  down  in  the  following  order: 
(i)  Men  of  the  upper  classes,  (2)  men  of  the  lower 
classes,  (3)  women  of  the  lower  classes,  (4)  women 
of  the  upper  classes.  This  proportion  holds  good 
equally  for  the  local  divisions  in  and  about  the  four 
large  cities  mentioned,  excepting  in  the  case  of  Phila- 
delphia; here  among  the  women  the  larger  per  cent. 


212  ETIOLOGY. 

was  with  those  of  the  higher  classes.  There  is  no  ex- 
planation to  offer  for  this  variation  from  the  general 
rule.  Whatever  ma}'  be  the  truth  in  respect  to  the 
general  rule,  one  fact  is  assured — the  disease  is  on  the 
increase.  The  restless  pursuit  of  wealth  and  social 
position,  the  anxiety  and  hurry,  emotional  strain  and 
intellectual  overwork,  the  unhygienic  modes  of  life  and 
especially  of  the  laboring  class,  the  excesses  in  excite- 
ment and  excitants  together  with  syphilis,  tend  to  fix 
on  modern  civilization  a  most  deadly  foe,  unknown 
in  former  times. 

PARESIS    IN    A    MULATTO    WHO    HAD    BEEN    FORMERLY    A 

SLAVE. 

G.  R.,  a  mulatto,  male,  age  22,  of  large  stature,  and 
fine  athletic  appearance,  admitted  July  5,  1855.  He  was 
a  native  of  Maryland  and  had  been  a  slave.  His  insanity 
was  ascribed  to  excitement  at  a  religious  meeting.  On 
admission  he  was  tranquil  and  very  docile,  but  was  sub- 
ject to  short  and  very  violent  paroxysms,  in  which  he  was 
dangerously  furious.  His  bowels  were  usually  constipated 
before  these  attacks.  He  complained  of  want  of  feeling 
in  his  feet  and  the  anterior  surface  of  his  legs.  He  had  a 
great  desire  for  education  and  often  wept  because  he  could 
not  read.  Once  he  escaped  from  the  asylum  grounds  but 
was  brought  back  and  on  the  twenty-third  day  after  admis- 
sion killed  himself  by  jumping  from  the  asylum  roof. 
(Abstract,  Workman,  American  Journal  of  Insanity,  Vol. 
13,  p.  22.) 

Excesses. — Alcoholic  and  sexual  excesses,  indulged 
singl}'  or  combined,  are  especially  potent  causes  of 
the  disease. 

With  the  excessive  use  of  alcohol  the  effect  in 
some  cases  is  direct,  and  the  most  conservative  of 
writers  say  that  it  is  prolific  in  its  tendency  when 
intellectual  or  emotional  strain  exists.  "  A  mere 
physiological  hyperemia  of  the  brain,  under  the  use 


EXCESSES.  213 

of  alcohol,  may  become  pathological  and  determine 
the  onset  of  paresis"  (Dercum). 

In  a  table  prepared  by  Mickle  from  Reports  of  the 
Commissioners  in  Lunacy  (England),  by  far  the 
highest  percentage  (21.4)  was  attributed  to  intemper- 
ance in  drink.  Some  other  statistics  give  as  high  as 
thirty  per  cent. 

Of  sexual  excess,  there  has  been  some  confusion 
as  to  the  excess  producing  the  disease  and  the  excess 
which  is  a  common  early  symptom  of  the  disease. 
It  is  an  early  symptom  in  some  cases,  as  are  many 
of  the  irregularities  of  the  life  in  the  early  stages  of 
the  malady,  but  usually  this  as  a  symptom  continues 
only  a  short  time,  while,  if  the  facts  can  be  secured 
in  very  many  cases,  a  history  of  earlier  excesses  will 
be  found.  It  is  recognized  as  an  exhausting  cause 
and  in  conjunction  with  prolonged  anxiety,  or  exces- 
sive emotional  strain,  or  even  exhausting  physical 
work,  it  tends  to  bring  about  the  conditions  of  the 
disease.  Savage  sums  up  his  researches  thus :  "  Gen- 
eral paresis  usually  arises  from  a  combination  of 
causes,  the  most  common  direct  cause  being  excesses 
of  all  kinds,  whether  sexual  or  alcoholic,  which  act 
more  powerfully  when  associated  with  strain,  worry 
and  anxiety." 

GENERAL    PARESIS    IN   WHICH    EXCITEMENT    AND    EXCESSES 
PLAY    A    PROMINENT    PART. 

A  case  of  this  nature  presented  expansive  ideas  and  pro- 
jects, great  restlessness  and  some  excitement  with  moral 
defect,  the  physical  symptoms  being  obscure.  After  three 
months  an  abatement  of  the  conditions  occurred,  so  that 
some  of  his  friends  insisted  that  a  mistake  had  been  made 
in  diagnosis  and  he  was  set  at  liberty.  But  he  soon 
plunged  into  a  life  of  speculation,  became  indecent  in  lan- 
guage  and  lascivious  in  conduct,   and  died  in  less  than 


214  ETIOLOGY. 

three  years  of   general   paresis.     (Abstract,  Stearns,  o-p. 
ci'L,  p.  509.) 

A    CASE    OF    GENERAL    PARESIS,    THE    RESULT    OF    INTEM- 
PERATE   PARENTS. 

A  boy,  cSt.  16,  showed  progressive  paralysis,  with  com- 
plete fatuity  and  great  emaciation,  also  contractures.  He 
was  in  a  very  demented  state  a  year  before  death.  Father 
was  English,  mother  Italian  ;  both  very  intemperate.  Par- 
ental neglect  and  semi-starvation  were  prominent  features 
in  the  case.  (Abstract,  Wiglesworth,  Journal  of  Mental 
Science,  Vol.  39,  p.  367.) 

Toxic  Agents. — Aside  from  the  toxin  of  syphilis,  that 
takes  so  important  a  role,  as  a  causative  factor  in  the 
disease,  there  has  been  of  late  years  a  tendency 
among  man}^  of  the  best  neuro-pathologists  to  accept 
the  theory,  which  was  first  put  forth  by  Angiolla, 
that  general  paresis  is  a  toxic  atiectioii  produced  by 
auto-intoxication,  either  directly  or  indirectly,  through 
an  interference  with  nutrition.  It  is  in  this  malign 
way  that  lead  (Kierman  et  a/.)  and  tobacco  (Guis- 
lain  ef  aJ.)  are  supposed  to  act  in  the  few  cases  that 
now  and  then  are  ascribed  to  these  agencies  as  the  ex- 
citing cause.  According  to  these  observers  the  bane- 
ful influence  of  alcoholic  a'buse  and  licentiousness, 
as  well  as  mental  overstrain,  is  to  be  sought  also  in 
these  nutritional  defects  that  contaminate  the  blood 
with  poisonous  products,  which  induce  the  degener- 
ative changes  in  the  nervous  tissues. 

Injury  to  the  Head. — Trauma  of  the  head  is  recog- 
nized as  a  cause  of  general  paresis.  In  the  four  thou- 
sand two  hundred  and  eight3--four  cases  collected  by 
jNIickle  two  hundred  and  eighty  were  attributed  to  such 
injury.  Probably  a  large  number  of  the  cases  with  little 
mental  derangement,  found  for  the  most  part  in  general 
hospitals,  are  those  which  result  from  this  cause. 


INJURY    TO    THE    HEAD.  215 

Dercum-^  gives  this  theory  in  explanation:  "Con- 
cussion of  the  brain  seems  to  lessen  its  power  of 
resistance,  perhaps  affects  directly  the  vaso-motor 
control  of  its  larger  vessels  and  thus  predisposes  it 
more  readily  to  attacks  of  congestion.  It  is  very 
probable  that  sunstroke  acts  very  much  as  does  con- 
cussion of  the  brain,  namely  by  predisposing  the 
organ  to  hyperemia  and  by  lessening  its  power  of 
resistance."  In  ninety-seven  of  the  above  cases 
given  by  Mickle,  sunstroke  was  the  assigned  cause. 

In  cases  of  trauma  paresis  may  follow  at  once,  but 
more  frequently,  it  is  years  before  the  disease  appears 
and  then  it  is  a  gradual  development. 

GENERAL    PARESIS    FROM    INJURY    TO    THE    HEAD. 

One  was  a  man  in  the  dock  yards,  the  other  a  butler. 
Both  immediately  developed  general  paresis.  A  predis- 
position already  existed,  the  blow  being  an  exciting  cause. 
(Abstract,  Rayner,  Journal  of  Mental  Science,  Vol.  37, 
p.  488.) 

A  CASE  OF  GENERAL  PARESIS  FROM  A  BLOW  ON  THE 

HEAD. 

An  engine-driver  at  the  Hullborough  Asylum  six  years 
before  admission  had  a  fall  on  the  back  of  his  head  ;  he  had 
not  been  the  "  same  man  "  afterward.  He  became  irritable, 
especially  with  his  children ;  threw  knives  at  them  and 
tried  to  stick  needles  into  their  eyes.  When  he  came  to  the 
asylum  he  was  unsteady  in  his  walk,  which  he  attributed 
to  "  a  stroke."  Fifteen  months  afterwards  he  was  far 
advanced  in  general  paresis  ;  his  gait  was  bad  ;  his  articu- 
lation drawling;  pupils  unequal.  He  said  he  was  "all 
right,"  but  thought  that  some  one  had  taken  him  out  of  bed 
during  the  night  and  set  fire  to  it.  (Abstract,  Bucknill  & 
Tuke,  Psych.  Med.,  p.  313.) 

*  Nervous  Diseases,  p.  670. 


2l6  ETIOLOGY. 

A    CASE    OF    GENERAL    PARESIS    RESULTING  FROM  FALL    ON 

HEAD. 

C.  H.,  set.  56  ;  fall  on  vertex  some  time  before  admission  ; 
insane  immediately  on  receipt  of  injury,  lasting  four  weeks 
with  maniacal  excitement.  Present  attack  six  months  pre- 
vious to  admission.  He  was  intemperate ;  pupils  irreg- 
ular ;  he  showed  ataxic  articulation  and  expansive  ideas, 
and  general  tremor  with  characteristic  physical  condition  ; 
apoplectic  seizures  seven  months  after  admission  ;  death 
from  exhaustion  fifteen  months  from  onset  of  disease. 
(Abstract,  Neff,  American  Journal  of  Insanity,  Vol.  53, 
p.  41.) 

A    CASE    DUE    TO    INJURY    OF    HEAD. 

L.  T.,  53,  moderate  drinker,  injury  to  head  four  months 
before  development  of  disease  :  unconsciousness  for  a  few 
hours  ;  acute  delirium  for  ten  days.  Immediately  after- 
wards mental  confusion,  loss  of  memory,  mental  enfeeble- 
ment,  apprehension,  expansive  ideas,  ataxic  gait,  occipital 
headache,  paresis  of  arms  and  legs,  aphasic  and  hesitating 
speech  ;  he  had  a  fair  realization  of  his  condition  ;  psychical 
symptoms  increased.  One  month  after  admission,  he  had 
general  clonic  convulsions,  terminating  in  paresis  affecting 
arms  and  legs.  Respiration  embarrassed  ;  patient  died  of 
asphyxia.     (Abstract,  Neff,  /oc.  ciL,  p.  41.) 

INJURY    TO    HEAD    THE    PREDISPOSING    CAUSE    OF    GENERAL 

PARESIS. 

A  man  who  had  an  injury  to  his  head,  became  insen- 
sible, recovered  and  remained  well  for  two  years  before 
symptoms  of  paresis  set  in.  (Abstract,  Mickle,  ride 
Sankey.) 

PARESIS    FOLLOWING  INJURY  TO  HEAD  OF  LONG  STANDING. 

The  history  of  a  case  of  general  paresis  showed  that  the 
patient  had  had  an  injury  to  his  head  many  years  before, 
and  he  bore  the  marks  of  cicatrices.  (Abstract,  Sankey, 
0^.  ci'L,  p.  287.) 


INJURY   TO    THE    HEAD.  217 

GENERAL    PARESIS    CAUSED    BY    THE    FIRING    OF 
A    LARGE    GUN. 

A  case  of  paresis  was  caused  by  the  firing  of  a  twenty- 
five-ton  gun  close  to  which  he  was  standing.  He  had  ex- 
alted delusions  on  admission,  declaring  that  when  he  shook 
his  fingers,  gold  dropped  from  them.  After  becoming 
quieter,  more  rational  and  his  memory  having  improved,  he 
fell  into  a  state  resembling  catalepsy.  About  6  A.  M.  of 
each  day,  he  would  pass  into  a  condition  of  perfect  stillness, 
lying  flat  on  his  back,  not  moving  a  muscle ;  this  con- 
tinued until  3  A.  M.  the  following  morning,  when  he  gave 
signs  of  life  by  speaking  to  the  attendant  and  swallowing 
food  placed  into  his  mouth.  At  6  A.  M.  when  the  stage  of 
stillness  was  coming  on,  he  would  perspire  profusely,  this 
gradually  diminishing  as  the  day  wore  on.  His  morning 
and  evening  temperature  rose  during  this  period  and  once 
or  twace  slight  twitches  were  observed.  He  w^as  apparently 
quite  unconscious,  pupils  sluggish,  sensation  and  motion 
suspended.  When  this  periodic  condition  finally  passed 
off  after  a  month's  duration,  he  was  comparatively  rational 
and  had  lost  his  more  prominent  delusions.  Four  months 
after,  these  delusions  returned  and  the  disease  steadily  pro- 
gressed. On  awakening  to  consciousness  in  the  morning 
he  was  evidently  under  the  influence  of  hallucinations  of 
hearing.     (Abstract,  Bucknill  &  Tuke,  op,  cit.,  p.  315.) 

CASES    OF    PARESIS    FOLLOWING    DEAFNESS,    MOTOR   NERVE 
ATROPHY   AND    TRAUMATISM    OF    BRAIN. 

(i)  G.  B.  A.  became  stone  deaf  in  one  ear  several  years 
before  he  developed  general  paralysis.  Clouston  believed 
the  case  was  one  of  propagation,  though  he  had  no  patho- 
logical proof  of  it.  The  patient  was  a  medical  man  and 
thought  that  the  symptoms  of  general  paralysis  which  fol- 
lowed were  due  to  the  extension  of  the  disease  of  his  in- 
ternal ear  into  the  brain.  (2)  Professor  Laycock  used  to 
quote  a  case  of  his  where  the  disease  had  spread  upwards 
from  a  Wallerian  atrophy  of  one  of  the  motor  nerves  of  one 
of  the  fingers.     (3)  G.  D.,  a  woman  of  36,  passed  gradu- 


2 1 8  ETIOLOGY. 

ally  into  quiet  non-delusional  general  paralysis  after  a 
small  punctured  wound  due  to  a  pitch-fork  in  the  top  of  her 
head,  penetrating  for  about  an  inch  into  the  brain.  After 
death,  all  the  convolutions  of  the  cortex  were  affected, 
especially  around  the  wound.  (Abstract,  Clouston,  Mental 
Diseases,  p.  390.) 

Epilepsy. — Epileps}'  is  not  a  common  predisposing 
cause  of  paresis,  but  its  action  on  the  brain,  inducing 
intense  cerebral  congestion,  does  undoubtedly  result 
in  paresis  at  times,  and  the  clinician  should  be  aware 
of  this  occasional  mode  of  development. 

Epilepsy  which  may  be  the  cause  of  paresis,  must 
not  be  confounded  with  the  epileptiform  attacks  which 
are  episodic  in  nature. 

Mendel  gives  two  cases  of  paresis,  one  of  a  man 
of  thirty-five,  who  had  been  epileptic  from  fourteen 
to  twenty  3' ears  of  age,  and  the  other  of  twentj^-eight 
years  of  age,  who  had  been  epileptic  from  his  eighth 
to  his  thirteenth  3'ear. 

GENERAL    PARESIS    IN    AN    EPILEPTIC. 

A  commercial  employe,  33,  had  been  an  epileptic.  He 
lost  his  wife  soon  after  marriage,  causing  him  deep  grief. 
He  died  of  paresis  in  asylum  three  years  after  admission. 
He  did  not  have  an  epileptiform  attack  in  the  asylum. 
(Abstract,  Christian,  American  Journal  of  Insanity,  Vol. 
44,  p.  498.) 

GENERAL    PARESIS    DEVELOPING    IN    AN    EPILEPTIC. 

J.  N.,  male,  ast.  32;  native  of  Ireland;  inmate  of  the 
asylum  for  nearly  five  years  ;  had  been  formerly  epileptic, 
but  not  so  latterly.  His  head  was  very  large  and,  phren- 
ologically,  well  formed.  He  was  very  quiet  and  childish  ; 
his  general  health  feeble.  Three  weeks  before  death  he 
complained  of  pain  in  various  parts  of  his  body  and  was 
confined  to  bed.  On  the  day  before  his  death,  he  had  a 
fit  of  syncope,  from   which    he   soon  rallied  but  showed 


Plate  ^ 


GENERAL  PARESIS  FOLLOWING  EPILEPSY. 

This  patient  had  been  an  epileptic  for  twenty  years  before  the  symptoms  ot  general 
paresis  developed. 


EPILEPSY.  219 

difficulty  in  breathing  and  depression.  A  few  hours  after 
he  complained  of  pain  in  the  lower  part  of  his  chest  and 
died  on  the  following  morning.  (Abstract,  Workman, 
loc.  cit.,  Vol.  13,  p.  18.) 

GENERAL    PARESIS    IN    WOMAN. HISTORY  OF    EPILEPSY. 

DURATION    TWO    AND    A    HALF    YEARS. 

K.  W.,  a  mistress,  set.  28,  fair  education,  formerly 
a  lady's  maid.  Admitted  in  August.  She  had  been  sub- 
ject to  epilepsy  from  the  age  of  9  to  12  ;  father  and  uncle 
epileptic,  and  died  imbecile;  "  on  the  fits  leaving  her  she 
became  altered  in  disposition,"  probably  at  puberty.  She 
was  always  of  a  haughty,  ambitious  character ;  left  service 
and  was  kept  in  luxury  by  a  gentleman  for  some  years ; 
afterwards  was  left  for  six  months,  but  still  supplied  with 
means  ;  supposed  to  have  become  addicted  to  drink,  became 
invalided  and  for  a  time  was  ill,  nature  of  illness  uncer- 
tain, had  to  part  with  all  her  goods  ;  was  maintained  by  her 
female  companions  ;  drank  more  and  was  at  times  muddled 
for  a  whole  week  together.  Gradually  became  affected 
in  mind,  excited  at  times,  talked  to  herself,  when  addressed 
would  not  reply,  restless,  would  dress  and  undress  repeat- 
edly during  the  day,  slovenly  in  her  person,  was  taken  to 
workhouse,  where  she  was  described  as  indecent  in 
behavior,  frequently  exposing  herself,  talking  to  imagi- 
nary people,  restless,  said  she  had  large  property.  On 
admission  to  asylum,  not  noisy,  restless,  answers  questions 
in  a  whisper,  talks  to  herself.  Slept  well,  expression  of 
vacancy  and  confusion,  frowns  and  knits  her  brows,  pupils 
equal  and  act  well,  does  not  know  how  long  she  has  been 
in  the  asylum  (came  yesterday)  ;  cannot  tell  the  day  of 
the  week,  has  no  headache,  very  untidy  in  dress,  tongue 
tremulous  and  clean,  bowels  not  open  since  admission,  no 
chest  symptoms.  Nothing  peculiar  in  gait,  pulse  80,  she 
is  pale,  in  fair  bodily  condition.  First  month,  right 
pupil  large ;  she  is  occasionally  violent ;  walks  with  firm 
step.  Second  month,  good  bodily  health,  pupils  un- 
equal ;  she  cannot  understand  what  is  said,  right  ear 
swollen.     Sixth    month,    drawling  tone,  violent  at  times 


220  ETIOLOGY. 

and  very  noisy,  walks  well,  but  frequently  falls  as 
though  her  knees  gave  way.  Ninth  month,  one  morning 
she  appeared  to  have  lost  use  of  left  side,  in  afternoon 
walked  with  limp  on  left  leg.  Fifteenth  month,  more 
paralyzed,  mind  very  imbecile,  mutters  unintelligibly,  wet 
and  dirty,  swallows  with  difficulty,  dejections  passed 
unconsciously,  sordes  collected  on  teeth.  Sixteenth 
month,  pupil  dilated  ;  she  is  unable  to  stand,  rallied  a  little 
in  mind,  swallows  rather  better,  conjunctiva  injected, 
failed  slowly  to  eighteenth  month ;  both  pupils  became 
contracted.  Death  by  exhaustion.  (Abstract,  Sankey, 
of.  at.,  p.  322.) 

Physical  Ovenvork  and  Strain. — Exhausting  physical 
labor  is  to  a  certain  extent  undoubtedly  an  exciting 
cause  of  general  paresis,  especially  when  not  coun- 
teracted by  pleasant  diversion,  or  by  intellectual  ex- 
ercise. This  is  particularly  true  when  acting  upon 
those  in  whom  the  nervous  system  has  lost  the  elas- 
ticity of  youth  and  its  ability  to  respond  after  fatigue. 

If  the  condition  of  the  system  has  been  impaired  by 
the  use  of  alcohol,  it  is  then  especially  susceptible  to 
the  effects  of  steady  overwork.  It  is  not  the  work 
that  kills;  seldom,  perhaps  never,  does  this  of  itself 
end  in  general  paresis;  but  the  endless  monotony,  the 
subjection  to  extreme  heat,  sudden  changes  of  heat 
and  cold,  tend  to  wear  on  and  weaken  the  central 
nervous  system,  and  when  this  condition  is  associated 
with  ill-regulated  passions,  strain,  poverty,  anxiety, 
or  extreme  disappointment,  the  brain  falls  a  ready 
prey  to  paresis. 

GENERAL    PARESIS    INDUCED    BY    EXPOSURE    TO    COLD. 

The  patient,  a  man,  reached  home,  having  been  out  in  the 
snow  all  night  and  from  this  time  had  violent  pains  in  his 
limbs.  Two  years  afterward,  his  pains  ceased  and  then 
he  began  to  show  symptoms  of  paresis.  (Abstract,  Chris- 
tian, loc.  cit..  Vol.  44,  p.  496.) 


INTELLECTUAL    OVERWORK.  221 

Intellectual  Overwork,  Anxiety,  Mental  Shocks  Etc. — 
Intellectual  work  done  judiciously  should  never 
injure.  Even  neurasthenia  claims  a  lower  percent- 
age of  professional  and  intellectual  men  than  those 
of  other  occupations.  But  forced  intellectual  labor, 
carried  on  with  imperfect  training,  creates  anxiety 
and  uneasiness,  continually  weighs  down  the  spirits, 
disturbs  the  sleep,  wears  with  special  force  on  the 
brain,  and  readily  predisposes  to  paresis. 

Again,  the  early  training  may  have  been  thorough, 
but  if  one  is  obliged  to  work  under  keen  emotional 
strain,  or  excessive  anxiety,  especially  if  fatal  re- 
verses threaten,  the  constitution  must  be  strong  and 
the  control  over  self  sufficient,  if  one  is  to  escape 
from  the  ill  consequences  of  such  conditions.  Paresis 
is  well  said  to  be  the  disease  of  civilization  —  the 
disease  of  mental  stress.  It  is  the  worry  rather  than 
the  work  that  does  the  damage.  Savage  says: 
"  General  paralysis  occurs  mostly  in  the  anxious- 
minded,  conscientious  man,  and  as  far  as  my  expe- 
rience among  the  middle  classes  is  concerned,  it  is 
rather  due  to  overstrain  than  to  overwork." 

Excessive  worry  and  anxiety  in  one  case  may  in- 
duce mania  or  melancholia,  while  in  another  paresis. 
Stearns  refers  to  a  table  of  six  hundred  and  thirty- 
four  cases  of  paresis,  of  which  one  hundred  and  six 
were  attributed  to  "  largely  reverses  in  fortune,  grief, 
anxiety,  and  distress  arising  from  unfortunate  social 
relations."  Of  Mickle's  table,  fifteen  per  cent,  were 
assigned  to  mental  anxiety,  adverse  circumstances, 
worry  and  overwork. 

GENERAL    PARESIS    CAUSED    BY    MENTAL    STRAIN,    WORRY, 
AND    ANXIETY. 

An  energetic  manager  of  a  successful  business  prose- 
cuted some  workmen  under  him  for  want  of  performance 

19 


222  ETIOLOGY. 

of  their  duties.  He  failed  to  get  a  conviction,  which  led  to 
a  conspiracy  of  the  workmen,  and  the  result  was  that  his 
life  was  rendered  miserable  by  a  system  of  threatening  and 
intimidation.  Sleeplessness,  worry  and  loss  of  appetite 
were  followed  by  the  ordinary  symptoms  of  general  pare- 
sis.    (Abstract,  Savage,  of.  cit.,  p.  284.) 

GENERAL    PARESIS     FOLLOWING    MENTAL    SHOCK. 

A  man  acquired  general  paresis  who  suddenl}'-  found 
that  his  son  had  forged  his  name  for  a  large  amount. 

FOLLOWING    MENTAL    SHOCK. 

A  widow  lost  her  onl}"-  child  by  a  fever  in  a  few  days 
while  traveling  abroad. 

GENERAL    PARESIS    FOLLOWING    GRIEF. 

A  man  returning  from  India,  lost  his  wife  during  the 
voyage  and  a  child  directly  after  landing. 

FOLLOWING    LOSS    IN    STOCK    MARKET. 

A  speculator  in  the  stock  exchange,  on  losing  a  very 
large  amount  of  money,  acquired  general  paresis. 

FOLLOWING    GRIEF    AND    DISAPPOINTMENT. 

A  widower,  left  with  two  sons,  after  carefully  superin- 
tending their  youth,  found,  on  their  coming  of  age,  that 
they  both  threw  off  their  allegiance  and  launched  into 
extravagance  and  vice,  one  of  them  speedily  drinking 
himself  to  death.  The  other  began  to  follow  the  same 
course.  The  father  acquired  general  paresis  on  the  death 
of  the  eldest.     (Abstract,  Sankey,  op.  cit.^  p.  291.) 

GENERAL    PARESIS    FROM    OVER-JOY. 

A  hair-dresser's  wife  with  a  family  of  children  had  been  in 
a  state  of  destitution  all  winter.  One  morning  her  husband 
came  home  with  the  news  that  he  had  got  permanent  em- 
ployment and  gave  her  a  sovereign  which  had  been  ad- 
vanced to  him.     In  the  evening,  he  found  that  she  had 


INTELLECTUAL    OVERWORK.  223 

spent  the  sovereign  wholly  in  buying  carpet-slippers  which 
she  said  she  meant  to  sell  for  a  large  sum.  In  this  case 
the  exciting  cause  was  over-joy.  (Abstract,  Sankey,  o^. 
cit.,  p.  291.) 

DISAPPOINTMENT    THE    EXCITING    CAUSE    IN    A    CASE 
OF    PARESIS. 

A  navy  officer  became  engaged  to  the  adopted  daughter 
of  a  wealthy  bachelor  uncle  who  permitted  the  marriage 
on  condition  that  the  officer  should  give  up  his  profession 
and  live  near  him,  he  making  them  a  handsome  allowance. 
But  the  uncle  married  his  nurse  and  changed  his  will  so 
that,  on  his  death,  his  niece  was  deprived  of  all  her  expec- 
tations and  her  husband  developed  general  paresis.  The 
actual  catastrophy  only  acted  as  an  exciting  cause  probably 
for  the  husband  had  amaurosis  at  the  time.  (Abstract, 
Sankey,  o;p.  cit.,  p.  290.) 


CHAPTER    XVI. 

GENERAL    PARESIS    FOLLOWING  ORDINARY   INSANITY. 

General  paresis  seldom  occurs  in  ordinary  insan- 
ity, yet,  as  pointed  out  by  Mickle,  the  operation  of 
new  agencies,  or  the  aggravation  of  old  ones,  may 
light  up  general  paresis  in  a  chronic  case  of  insanity. 

GENERAL    PARESIS    WITH    PERIODS    OF    MANIACAL     EXCITE- 
MENT   ALONE    FOR    SEVERAL    YEARS. 

G.  G.,  set.  36.  Irish,  drunken  and  hard-working,  mar- 
ried. He  had  an  attack  of  "  acute  mania"  in  1876,  was 
sent  to  the  asylum  and  "recovered"  in  five  weeks.  No 
evidences  of  general  paralysis  were  noted.  Again  in  1878 
he  had  a  similar  attack,  but  no  diagnosis  was  made,  al- 
though some  suspicion  of  the  disease  was  excited,  and  it 
was  only  after  his  third  admission  in  1879,  ^^^^  ^^^^  disease 
was  fully  manifest.  He  died  with  it  in  1882.  His  wife 
showed  that  he  was  weakened  intellectually  after  his  first 
attack.      (Abstract,  Clouston,  Mental  Diseases,  p.  393.) 

GENERAL     PARESIS    WITH    MANIACAL    EXALTATION     ALONE 
FOR    MONTHS. 

G.  H.  was  acutely  maniacal,  very  dangerous,  homicidal, 
impulsive,  strong-willed  and  unmanageable  for  twelve 
months,  before  there  were  any  motor  s^'mptoms  that  en- 
abled Clouston  to  diagnose  general  paralysis.  From  the 
state  of  his  pupils  and  the  expression  of  his  face,  he  sus- 
pected it,  but  he  could  not  say  definitely  it  was  any  other 
condition  than  acute  mania  for  the  first  year.  (Abstract, 
Clouston,  op.  cit.,  p.  394.) 

224 


PARESIS    FOLLOWING    ORDINARY    INSANITY.     225 
GENERAL    PARESIS    DEVELOPING    IN    AN    IMBECILE. 

M.  Christian  relates  a  case  of  general  paresis  in  a  man 
who,  born  in  1824,  was  under  treatment  from  1855  to  i860 
by  Calmeil  as  an  imbecile.  His  friends  assumed  the  care 
of  him  until  1878,  when  he  again  became  disturbed,  having 
delusions  of  persecution  and  manifesting  marked  mental 
enfeeblement.  Cerebral  congestions  became  frequent  and 
general  paresis  appeared  and  followed  a  usual  course. 
(Abstract,  American  Journal  of  Insanity,  Vol.  37,  p.  449.) 


DEVELOPMENTAL  GENERAL  PARESIS  IN  A  CONGENITAL 

IMBECILE. 

Margaret  C,  first  admission,  ast.  17,  had  no  relatives  to 
tell  her  history,  but  was  regarded  as  a  case  of  congenital 
imbecility.  She  was  said  to  have  been  insane  for  at  least 
three  years ;  she  was  undersized,  badly  developed,  with 
considerable  mental  enfeeblement.  There  was  mild  ex- 
altation ;  when  spoken  to  she  usually  smiled  foolishly,  said 
she  felt  fine,  memory  much  impaired,  no  delusions,  no 
motor  symptoms.  While  in  the  asylum,  she  picked  up  a 
little,  was  slow  in  her  movements,  occasionally  quarrel- 
some, liable  to  fits  of  rage  or  slight  excitement,  but  gen- 
erally happy.  After  sixteen  months,  she  was  transferred 
to  lunatic  wards  of  poorhouse  and  then  boarded  out  in  the 
country.  Readmitted  to  asylum  three  years  after  dis- 
charge. During  this  time,  almost  nothing  could  be  learned 
of  her  condition.  She  remained  fairly  quiet  and  manage- 
able, but  mental  enfeeblement  had  steadily  progressed  ;  she 
became  very  weak  in  body,  could  not  stand,  some  paresis 
of  right  side  and  considerable  difficulty  in  swallowing. 
Her  mind  was  almost  a  complete  blank  ;  she  seldom  spoke, 
voice  monotonous  and  tremulous,  lips  and  hands  tremulous. 
The  disease  had  reached  a  very  advanced  stage.  She  died 
ten  days  after  admission  of  pneumonia  in  a  phthisical  lung. 
The  case  was  not  thought  to  be  general  paresis  until  post- 
mortem. (Abstract,  Middlemass,  Journal  of  Mental 
Science,  Vol.  40,  p.  37.) 


2  26     PARESIS    FOLLOWING    ORDINARY    INSANITY. 

A  CASE    OF    GENERAL    PARESIS    RAPIDLY   FATAL.       THE 

PATIENT    HAD    RECOVERED    FROM    AN    ATTACK 

OF    INSANITY    SEVEN    YEARS    BEFORE. 

E.  G.,  married,  ret.  33  ;  grandfather  melancholy,  parents 
healthy.  The  supposed  cause  of  this  attack  was  anxiety 
about  money  matters.  There  was  a  history  of  a  previous 
attack  of  insanity,  seven  years  before,  with  complete  re- 
covery. This  attack  began  with  hesitation  in  speech, 
great  incoherence,  sleeplessness,  and  refusal  to  take  food. 
He  fancied  his  shop  assistants  were  being  starved,  and  that 
people  were  removing  goods  without  payment.  He  was 
found  on  admission  to  be  weak,  nervous  and  restlessly  ex- 
citable. In  three  months,  he  was  very  feeble  on  his  legs 
and  hard  to  understand  due  to  thick  speech.  Later  he  had 
a  convulsive  fit,  from  which  he  recovered,  but  remained  in 
a  half  dazed  condition-.  There  was  no  special  paralysis 
but  great  exaggeration  in  reflexes  four  months  after  admis- 
sion. He  was  found  one  morning,  unconscious,  head  turned 
to  right,  conjugate  deviation  of  the  eyeballs  to  right ;  pulse 
170,  respiration  55,  temperature  105°;  right  pupil  slightly 
larger  than  left ;  loss  of  power  of  rectum  and  bladder ; 
Cheyne-Stokes  breathing  ;  he  sank  into  deep  unconscious- 
ness and  died.     (Abstract,  Savage,  o^.  cit.,  p.  296.) 

GENERAL  PARESIS  PRECEDED  BY  ACUTE  MANIA  IN  YOUTH. 

G.  H.  A.  had  an  attack  of  mania  in  youth,  recovered, 
kept  well,  and  performed  his  ordinary  business,  and  at  the 
age  of  44  became  a  general  paralytic.  (Abstract,  Clous- 
ton,  op.  cit.,  p.  395.) 

HYSTERICAL    INSANITY    FOLLOWED    BY    GENERAL    PARESIS. 

Woman,  33,  an  ordinarily  violent,  maniacal  patient, 
somewhat  hysterical ;  duration  of  insanity  given  as  two 
years.  The  symptoms  commenced  by  hysterical  crying 
and  agitation.  Only  motor  signs,  exaggerated  reflexes 
and  hysterical  shaking ;  she  gradually  quieted  down ; 
paretic  symptoms  some  months  later,  were  typical  during 
her  decline  and  death ;   she  died   after  one  year  and  ten 


PARESIS    FOLLOWING    ORDINARY    INSANITY.     227 

months.     (Abstract,  Phelps,  American  Journal  of  Insanity, 
Vol.  53,  p.  59.) 

GENERAL    PARESIS     SUPERVENING    ON    CHRONIC    MANIA    OF 
LONG    DURATION. 

Jane  M.,  ast.  40,  Irish,  occupation,  domestic  ;  duration  of 
insanity,  many  years  ;  diagnosis,  chronic  mania.  History 
on  admission,  she  had  delusions  of  poison,  and  had 
haunted  the  Supreme  Court  for  years,  thinking  she  had 
a  suit  there.  She  improved  physically,  mentally  she  re- 
mained the  same  ;  she  was  removed  to  almshouse.  Read- 
mitted to  asylum  June,  1881,  age  50,  single.  Excitable, 
very  talkative,  disconnected  ;  thinks  she  has  been  poisoned 
by  a  certain  doctor,  who  would  put  her  out  of  the  way 
if  he  could,  that  he  might  not  be  found  out ;  that  she  has 
recovered  a  large  amount  of  money  from  him  on  a  suit ; 
that  the  British  Government  has  given  her  $15,000  to-day, 
that  she  was  to  be  married  to  a  lawyer  last  night  and  that 
another  gave  $2,000  to  have  her  arrested  because  he 
wanted  to  marry  her  himself.  She  is  below  medium 
height  and  thin ;  right  pupil  small  and  inactive  to  light, 
left  one  more  dilated,  also  inactive.  Previous  history: 
Always  considered  eccentric,  not  ordinarily  intelligent  •, 
limited  education,  temperate  habits,  cheerful  and  frank. 
It  is  believed  that  a  disappointment  in  marrying  first 
caused  her  alienation.  First  decided  symptoms  observed 
twelve  years  ago ;  delusion  that  she  was  going  to  marry 
some  rich  man ;  she  has  grown  thin  and  more  demented, 
always  harmless,  happy  and  neat.  October,  1881,  marked 
delusions  of  hearing.  She  listens  at  the  ventilators  to  peo- 
ple whom  she  thinks  are  talking  to  her.  She  says  that  her 
people  are  here  ;  she  is  quiet,  tractable,  neat.  April,  1882, 
she  continues  to  hear  devils  at  times,  and  is  noisy ;  she 
scolds  incoherently  and  breaks  glass.  November,  1884, 
she  walks  the  floor,  listening  to  voices  which  come  from 
below  ;  she  is  much  demented.  She  says  she  has  five  gifts 
in  her  eye,  that  she  must  walk  all  the  time  and  be  fed  on 
bread  and  water  ;  left  pupil  large  and  immobile,  lens  cloudy. 
March,   1892,  no  great  change,    except  that  she  is  more 


2  28     PARESIS    FOLLOWING    ORDINARY    INSANITY. 

demented  and  senile.  December,  1892,  she  had  two  epi- 
leptic convulsions,  and  has  become  untidy.  January,  1894, 
she  has  had  a  few  epileptic  convulsions,  usually  at  night ; 
she  is  much  demented.  April,  1895,  she  is  very  demented 
and  weak ;  she  walks  about  and  often  falls  and  hurts  her- 
self ;  she  is  good-natured,  very  untidy.  No  convulsions 
lately.  April,  1895,  she  had  convulsions  two  days  ago 
and  another  last  night ;  she  has  been  in  bed  for  three  days 
in  a  weak,  confused  way.  August,  1895,  pupils  unequal, 
left  dilated,  both  inactive  to  light;  articulation  indistinct, 
knee-jerks  absent,  walk  feeble.  She  stands  without  sway- 
ing with  eyes  closed ;  feeble  circulation,  extremities  blue 
and  cold ;  she  is  getting  gradually  weaker  and  more  de- 
mented;  she  died  in  October,  1895.  (Abstract,  Worcester, 
American  Journal  of  Insanity,  Vol.  52,  p.  319.) 

THREE    CASES    OF    GENERAL    PARESIS    AND    CHOREA. 

In  the  first  case,  the  patient  had  many  attacks  of  chorea 
from  infancy  up  to  the  beginning  of  his  paresis  at  33.  In 
the  second  the  paretic  symptoms  only  partially  a^ected 
the  choreic  ones.  In  the  third  case,  the  choreic  move- 
ments were  rhythmic  or  localized  in  a  member  in  the  form 
of  paroxysmal  attacks  like  the  movements  and  contractions 
of  Jacksonian  epilepsy.  (Abstract,  Vallon  and  Marie, 
American  Journal  of  Insanity,  Vol.  51,  p.  233.) 

Remissions. — In  some  cases  remissions  occur,  usu- 
ally in  the  lirst  or  second  stage  of  the  disease,  lasting 
from  a  few  weeks  to  several  months;  even  after  a 
lapse  of  many  years  the  disease  has  been  known  to 
return,  but  the  average  duration  of  a  remission  is 
from  two  to  four  months.  A  remission  marks  a  ces- 
sation of  active  disease  for  the  time,  and  many  of 
the  s3'mptoms  disappear,  but  the  disease  is  not  eradi- 
cated, only  quiescent,  and  is  certain  to  reappear,  usu- 
ally in  a  more  active  form.  Some  patients  during 
a  remission  improve  in   mind  and  body  equally;  in 


REMISSIONS.  229 

others  the  improvement  in  mind  is  noted  without 
corresponding  motor  improvement. 

Remissions  have  been  known  so  complete  that 
every  motor  symptom  disappeared  and  the  mind 
seemed  as  clear  as  in  health;  these  at  times  have  been 
pronounced  cures,  but  generally  it  is  believed  that 
the  disease  does  not  let  go  its  hold  on  the  system 
and  that  it  is  sure  to  return,  sooner  or  later.  Bland- 
ford  says  of  some  such  seeming  cures:  "These  cases 
would  be  pronounced  sane  by  any  jury.  They  have 
either  lost  their  delusions,  or  are  able  to  conceal 
them.  I  have  received  letters  from  such  written 
without  a  mistake.  But  those  who  had  best  recovered 
are  long  since  dead,  and  I  know  of  no  one  whose 
disease  did  not  reappear  in  a  longer  or  shorter  time." 

Remissions  may  occur  at  any  time  in  the  progress 
of  the  malady,  but  they  shorten  in  duration  as  the 
disease  advances.  During  these  periods  of  cessation 
every  trace  of  maniacal  excitement  and  emotional 
display  may  cease,  but  some  delusion  frequently  con- 
tinues; or  a  slight  tremor  of  the  lip  or  hand,  an 
inequality  of  pupils,  some  defect  in  speech,  or  in  gait 
generall}^  remains.  If  every  other  mental  trace  dis- 
appears, there  sometimes  develops  some  moral  or 
esthetic  eccentricity,  i.  e.,  purposeless  lying,  irritability 
of  temper,  extravagance  in  buying;  or  the  only  sign  of 
disease  ma}^  be  a  stolid  or  troubled  expression.  The 
patient  is  apt  to  grow  stout  in  body  and  become  more 
feeble  in  cold  weather. 

Frequently  the  patient  feels  well;  he  converses 
intelligently,  his  interest  in  business  returns  and  he 
desires  to  resume  his  former  life.  But  if  permitted 
to  return  to  his  occupation  he  soon  becomes  con- 
scious of  a  weakness  in  continued  mental  effort,  or 
if  it  be  manual  work  he  finds  the  bodil}^  vigor  does 
not  return,  and  in  either  case  he  soon  breaks  down. 


230  GENERAL    PARESIS. 

It  is  agreed  that  the  enfecblement  of  mind  is  incom- 
patible with  perfect  responsibility;  that  under  the  best 
conditions  the  engaging  in  business  should  be  dis- 
couraged; that  only  quiet  surroundings,  free  from  ex- 
citement and  anxiety,  should  be  provided.  Medical 
care  and  treatment  should  continue  during  the  remis- 
sion, and  a  nurse  or  some  responsible  person  should 
keep  constant  supervision,  for  the  disease  will  surely 
appear  again,  and  frequently  its  reappearance  is 
marked  by  an  outburst  of  excitement  or  violence,  or 
by  an  epileptiform  seizure. 

GENERAL    PARESIS    WITH    MARKED    REMISSION. 

A  commercial  traveller,  with  a  history  of  drink,  was  ad- 
mitted with  all  the  physical  and  mental  symptoms  of  general 
paresis.  He  went  into  a  stage  of  complete  paralysis  and 
then  recovered  so  that  he  took  a  situation  again  at  £300  a 
year :  he  held  it  for  eighteen  months,  returned  to  asylum 
and  died  in  a  short  time  of  general  paresis  (Whitcombe). 

REMISSION    OF    EIGHTEEN    MONTHS    IN    SEA    CAPTAIN. 

A  captain  of  a  steamer  came  to  asylum  in  a  maniacal 
state.  After  a  few  months  of  this  excitement,  with  exalta- 
tion, he  quieted  down  and  seemed  to  recover  perfect!}" ;  he 
had  no  tremor  or  other  signs  of  general  paresis,  although 
paresis  was  suspected.  He  commanded  a  ship  eighteen 
months  and  the  only  difference  noticed  in  him  was  that  he 
was  more  placid  and  complaisant  than  formerly.  He 
returned  to  England  and  rapidly  broke  down  ;  he  became 
demented,  had  extreme  tremor  and  in  two  months  died  of 
epileptiform  convulsions.  (Abstract,  Whitcombe,  Journal 
of  Mental  Science,  Vol.  37,  p.  4S7.) 

A    REMISSION    OF    THREE    YEARS    OR    MORE. 

A  man,  a?t.  31  ;  after  some  eccentricities  became  mani- 
acal, with  much  exaltation,  extravagant  boasting,  letter 
writing  to  the  queen,  masturbation,  self-decoration,  etc. 
In  two  years  this  condition  subsided  and  he  became  taciturn 


REMISSIONS.  231 

and  hypochondriacal,  with  loss  of  expression,  thickness  of 
articulation,  fibrillar  tremor  and  incapacity  for  exertion. 
These  symptoms  vanished  and  for  three  years  he  has  been 
in  constant  and  responsible  employment.  (Abstract, 
Mortimer,  Alienist  and  Neurologist,  Vol.  10,  p.  489.) 

A    MARKED  REMISSION    AFTER  THREE  YEARS'  DURATION  OF 
THE    DISEASE. 

Man,  with  well-marked  symptoms  of  general  paresis. 
The  disease  went  on  for  two  years  and  he  nearly  died  of 
general  convulsions  but  after  a  time  began  to  improve ; 
he  remained  in  asylum  three  years,  then  went  abroad  and 
when  heard  of  some  years  later  was  still  well.  (Abstract, 
Rayner,  Journal  of  Mental  Science,  Vol.  37,  p.  487.) 

A    REMISSION    IN    A    MEDICAI.    MAN. 

A  medical  man  had  marked  symptoms  of  general  par- 
esis, who  had  taken  alcohol  and  all  kinds  of  drugs. 
Gradually  the  symptoms  passed  away,  he  was  discharged 
and  two  or  three  years  after,  he  was  again  a  "  dispenser." 
(Abstract,  Rayner,  loc.  cit.,  p.  488.) 

GENERAL    PARESIS    WITH    REMISSION    OF    SOMATIC 
SYMPTOMS. 

A  case  in  which,  during  periods  of  excitement  and  even 
in  conditions  of  exaltation,  the  somatic  symptoms,  which 
at  the  best  were  very  slightly  developed,  seemed  wholly 
in  abeyance.  Competent  experts  could  not  be  certain 
that  it  was  general  paresis,  though  it  proved  to  be  so. 
(Abstract,  Stearns,  op.  cit.,  p.  512.) 

A  REMISSION  OF  MORE  THAN  THREE  YEARS. 

Patient,  ast.  32,  had  been  very  restless  and  talkative, 
boasting  of  his  riches  and  adventures.  His  account  of  his 
life  was  incoherent  and  contradictory.  At  the  hospital  he 
was  singing  and  shouting  and  very  destructive ;  eight 
months  after  admission  he  had  a  paroxysm  of  maniacal 
violence.     On  admission,  he  had  numerous  exalted  delu- 


232  GENERAL    PARESIS. 

sions,  was  king  of  the  world,  brothers  were  kings,  could 
do  whatever  he  tried,  etc.  ;  speech  thick,  and  articulation 
at  times  difficult;  his  gait  very  unsteady  ;  temperature  98° 
in  the  morning,  and  99°  in  the  evening.  He  was  under 
treatment  for  a  year  when  he  began  to  improve  and  the 
exalted  delusions  passed  awa}-.  The  thickness  of  speech 
and  difficulty  in  articulation  remained,  although  in  a  less 
degree,  his  legs  still  were  weak.  He  remained  under 
observation  for  another  year  when  he  was  discharged. 
He  kept  well  for  over  three  3^ears  when  he  disappeared 
from  observation.  (Abstract,  Bucknill  &  Tuke,  Psycho- 
logical Medicine,  p.  330.) 

A  REMISSION  OF  THREE  YEARS.       THE   PATIENT  RETURNED 
TO  BUSINESS. 

In  one  case,  which  has  since  been  running  rapidly  a 
downward  course,  the  remission  lasted  three  years,  during 
which  time  he  attended  to  extensive  commercial  under- 
takings with  fair  success  and  took  charge  of  several  assign- 
ments.    (Abstract,  Spitzka,  o^.  at.,  p.  215.) 

A    REMISSION    OF    FIVE    YEARS'    DURATION. 

Patient  admitted,  supposed  to  have  general  paresis ; 
maniacal  excitement,  inequality  of  pupils,  blurring  of 
speech,  alteration  of  handwriting  and  knee  reflexes  af- 
fected. At  the  end  of  a  year  he  had  serious  convulsions, 
with  temporary  loss  of  power  on  left  side.  He  improved 
very  much  mentally  and  became  apparently  well  but  re- 
mained as  a  voluntary  boarder  until  a  few  weeks  ago — 
over  five  years.  Then  he  became  excitable  ;  handwriting 
changed,  left  out  words  and  letters.  He  is  occasionally 
wet  and  restless  ;  he  is  unmanageable,  tumbles  about,  and 
he  has  exalted  ideas  and  schemes.  (Abstract,  Whitcombe, 
loc.  cit.,  Vol.  37,  p.  487.) 

A    CASE    OF    GENERAL    PARESIS    WITH    A    REMISSION 
OF    MORE    THAN    NINE    YEARS. 

The  patient  had  usual  delusions,  twitches  of  facial  mus- 
cles, tremor  of  upper  lip,  thick  speech,  and  weakness  of 


REMISSIONS.  233 

the  knees,  and  was  violent  and  destructive.  He  gradually 
calmed  down,  became  quite  rational,  and  lost  all  abnormal 
symptoms,  except  the  tremor  of  lip  and  slight  thickness  of 
speech.  He  was  ill  for  three  months  and  was  kept  under 
observation  six  months  before  he  was  discharged.  He 
is  still  alive,  nine  years  since  discharge,  and  draws  his 
pension  regularly.     (Abstract,  Bucknill  &  Tuke,  of.  cit., 

P-  330-) 

A    COMPLETE    REMISSION    OF    LONG    DURATION. 

A  patient  had  been  transferred  to  an  asylum  eleven 
years  before,  certified  to  be  suffering  from  general  par- 
alysis. There  was  nothing  which  militated  against  such  a 
diagnosis  except  that  the  man  gradually  improved,  was 
discharged  and  for  years  after  supported  himself  by  his 
handicraft.     (Abstract,  Blandford,  op.  cit.,  p.  307.) 

A  remission  more  or  less  prolonged  sometimes  fol- 
lows fracture,  abscess,  erysipelas  or  some  other  inter- 
current disease  or  episode. 

GENERAL    PARESIS    WITH    IMPROVEMENT    FOLLOWING 
CARBUNCLES. 

-  A  man  with  general  paralysis,  who  had  been  in  the 
asylum  three  years,  developed  three  carbuncles  and  was 
expected  to  die,  but  is  now  getting  better.  (Abstract, 
White,  Journal  of  Mental  Science,  Vol.  37,  p.  488.) 

REMISSION    AFTER    A    LARGE    CARBUNCLE. 

Hurd,  H.  M.,  has  reported  a  case  of  remission  after  the 
patient  had  had  a  large  carbuncle  over  the  cervical  verte- 
bras.    (Abstract,  Stearns,  op.  cit.,  p.  508.) 

GENERAL    PARESIS    IN    WHICH    MARKED    IMPROVEMENT 
FOLLOWED    ABSCESSES. 

A  man  had  passed  through  the  early  stages  and  his 
friends  were  awaiting  his  death.  It  was  a  question  whether 
to  let  him  die  as  he  was  or  to  evacuate  three  or  four  ab- 
scesses which  he  had.     It  was  decided  to  evacuate  them, 


234  GENERAL    PARESIS. 

and  he  at  once  improved  and  has  remained  in  a  somewhat 
weak-minded  condition  for  about  six  years.  He  can  now 
play  tennis  well.  (Abstract,  Savage,  Journal  of  Mental 
Science,  Vol.  37,  p.  488.) 

A    CASE    OF    GENERAL    PARESIS    IN    WHICH    A    MARKED    RE- 
MISSION   OCCURRED    AFTER    AN    EXTENSIVE    SLOUGH. 

Male,  get.  40  ;  married  ;  native  of  Michigan  ;  formerly  hotel 
proprietor  and  of  average  business  capacity.  His  mother 
was  intemperate  and  her  family  subject  to  phthisis.  He 
was  also  intemperate,  reckless  in  his  expenditures  and  led 
a  fast  life.  After  marriage,  he  reformed  but  did  not  suc- 
ceed in  business.  There  was  no  history  of  syphilis.  After 
two  years  of  mental  infirmity,  he  was  admitted  to  asylum. 
At  first,  he  had  been  depressed  and  indifferent  to  business. 
After  a  year,  he  developed  delusions  of  grandeur.  His 
bodily  health  improved,  while  his  mind  grew  weaker.  Pre- 
vious to  admission,  he  had  remained  in  bed  for  several  weeks 
and  had  shown  a  great  tendency  to  sleep.  On  admission, 
he  weighed  one  hundred  and  seventy-seven  pounds ; 
height  medium  ;  bodily  health  fair ;  pupils  contracted  and 
right  larger  than  left ;  skin  dry ;  articulation  thick  and  in- 
distinct ;  temperature  99^  ;  great  ataxia  ;  expression  dull 
and  heavy;  fine  facial  lines  absent;  replied  to  questions  in 
a  drawling  way  and  often  his  replies  were  irrelevant ;  he  had 
delusions  of  grandeur  and  he  thought  himself  in  perfect 
health.  One  month  after  admission,  he  was  depressed, 
and  sat  quietly  alone,  apparently  reading.  He  showed 
stupidity  and  torpor,  was  dull,  anxious  to  go  to  bed  and 
would  fall  asleep  even  while  eating.  Extreme  debility  and 
paresis  were  present.  He  required  constant  personal 
attention.  His  articulation  was  clumsy  and  his  voice 
weak.  His  condition  passed  into  elation.  He  became 
mischievous,  threw  clothing  from  the  window,  appropriated 
others'  property.  On  January  6th,  about  a  year  after  ad- 
mission, he  had  an  apoplectiform  seizure,  with  choreiform 
movements  of  the  head,  twisting  of  the  mouth,  protrusion 
of  the  tongue  and  tossing  of  the  arms.  The  axillary  tem- 
perature was  103'^  ;  pulse  rapid  ;  pupils  contracted.    Tenth, 


REMISSIONS.  235 

continues  fairly  comfortable  in  bed,  with  no  convulsive  move- 
ments. He  is  eating  well  and  feeling  <'  first  rate."  Four- 
teenth, he  sits  up  and  pretends  to  read  a  paper.  Twenty- 
first,  he  does  not  recognize  an  old  acquaintance.  He 
is  very  untidy.  February,  he  is  able  to  be  about ;  quiet ; 
very  feeble  in  mind  ;  inclined  to  sit  alone  ;  inappreciative 
of  what  is  said  to  him  ;  gait  feeble.  He  has  sudden  im- 
pulses to  do  violence.  His  handwriting  is  totally  illegible. 
March,  he  is  again  elated  and  extravagant ;  he  forms  strange 
intimacies  and  promises  feeble-minded  patients  work  at 
immense  wages.  During  April,  he  had  rheumatoid  affec- 
tion of  the  joints.  He  was  confined  to  bed  and  grew  de- 
bilitated. There  was  tendency  to  engorgement  of  the  right 
lung.  May,  he  is  able  to  be  about.  June,  he  is  better 
mentally  than  at  any  time  since  coming  under  treatment ; 
quiet,  appreciative,  and  able  to  care  for  himself;  attends 
chapel  and  entertainments  ;  he  is  neat  in  dress  ;  he  shows 
a  disposition  to  assist  in  work ;  he  can  remember  names. 
The  improvement  fallowed  the  formation  of  a  large  gan- 
grenous slough  on  the  left  heel.  His  articulation  and 
gait  are  much  better.  He  can  write  legibly.  He  is  able 
to  write  letters ;  mind  is  quite  clear ;  he  is  contented  and 
cheerful;  he  has  no  delusions.  August,  he  thinks  himself 
well  enough  to  be  discharged  but  is  not  strenuous  about 
going  away.  His  writing  improves.  September,  he  is 
industrious  and  pleasant ;  enjoys  the  freedom  of  the 
grounds ;  plays  croquet.  On  November  25  he  was  re- 
moved by  his  wife  on  trial.  She  regards  him  as  well.  His 
mind  is  not  strong  but  the  progress  of  the  disease  seems 
arrested.  After  his  return  home,  he  took  care  of  horses. 
He  had  limited  endurance,  but  could  contribute  materially 
to  his  family's  support.  Thirteen  months  after  his  dis- 
charge, he  was  in  good  flesh  and  seemed  as  well  mentally 
as  when  he  left  the  asylum.  He  has  been  working  more 
or  less  ;  he  shows  a  pleasant  interest  in  the  institution  ;  re- 
cently he  has  experienced  pain  in  the  heel  on  which  the 
slough  appeared.  Present  condition  about  two  and  a  half 
years  after  discharge — he  has  improved  mentally ;  he  has 
been  out  of  employment  but  a  few  months  since  he  left  the 


236  GENERAL    PARESIS. 

asylum;  except  for  catarrh,  he  is  in  good  bodily  health; 
weight  165  pounds;  no  paresis  in  speech  or  gait ;  hand- 
writing regular ;  he  has  full  control  of  a  livery  stable  and 
earns  good  wages ;  he  keeps  his  books  accurately ;  and  he 
has  good  memory  for  remote  and  recent  events.  His  dis- 
position has  changed.  He  used  to  be  irritable  and  quick- 
tempered, but  is  now  always  good-natured.  His  habits 
are  temperate  and  regular.  (Abstract,  Burr,  C.  B.,  Ameri- 
can Journal  of  Neurology  and  Psychology,  1884.) 

Duration. — It  is  difficult  to  mark  a  general  average 
in  the  duration  of  this  affection,  for  many  factors 
combine  to  effect  its  progress.  The  special  form 
taken  by  the  disease  in  any  case  has  probably  the 
greatest  influence  as  to  the  length  of  time  required  for 
it  to  run  its  course.  The  so-called  ascending  form, 
i.  e.,  when  the  spinal  cord  is  affected  first,  is  slow. 
If  brain  and  cord  are  attacked  at  the  same  time  the 
duration  is  usually  short.  Cases  with  expansive  or 
exciting  delusions  proceed  with  greater  rapidity  than 
those  of  the  depressed  form. 

Again  the  average  course  of  the  disease  is  longer 
in  women  than  in  men,  in  those  who  have  lived  a  life 
of  comparative  comfort  than  in  the  poor,  and  in 
hereditary  cases  than  in  those  not  hereditary.  All 
factors  of  a  violently  disturbing  nature  hasten  the  end, 
while  all  quieting  influences  such  as  the  environment 
of  isolation,  cessation  of  business  trials,  and  absence 
from  home  cares  tend  to  prolong  the  life.  Perhaps 
there  is  no  factor  which  modifies  the  duration  so 
largely  as  remissions,  which  may  vary  in  length  from 
a  few  weeks  to  many  months.  One  of  the  difficulties 
of  determining  the  duration  is  frequently  the  impos- 
sibility of  fixing  the  time  at  which  the  disease  actu- 
ally began.  The  prodromal  stage  may  run  but  a  few 
months,  sometimes  a  few  years,  and  it  is  said  in  very 
exceptional    cases    that    it    may    last    nearly   a    life- 


DURATION.  237 

time.  Archer  gives  the  order  of  duration  ascending 
as  follows:  Cases  marked  by  excitement,  by  depres- 
sion, by  uniform  dementia,  by  alternating  excitement 
and  depression,  and  by  apoplectic  attacks. 

The  disease  is  progressive  and  if  uninterrupted  by 
remissions,  or  other  favoring  circumstances,  the 
patient  goes  steadily  down  to  death,  probably  before 
two  years  from  the  time  of  the  established  disease. 
It  is  said  that  more  patients  die  under  two  than  over 
five  years  after  attacked,  but  cases  have  been  pro- 
longed to  ten,  or  even  fourteen  years  or  more;  how- 
ever, a  case  lasting  ten  years  is  very  unusual.  Clous- 
ton  says :  "  So  far  as  I  am  aware,  no  case  with  every 
mental  and  bodily  symptom  of  general  paresis,  and 
diagnosed  by  many  competent  and  experienced 
specialists  to  be  such,  ever  lived  so  long  as  thirty 
years."  Blandford  gives  an  account  of  a  patient, 
who  lived  twenty-seven  years.  French  authors 
regard  the  average  as  less  than  two  years,  and  some 
English  writers  place  it  at  twenty-two  months. 
Dercum  says :  "  Males  generally  die  within  two  or 
three  years,  females  within  three  or  four,  while  the 
great  majority  of  all  cases  die  within  five  years. 
Nothing  more  definite  can  be  said  than  that  the  end 
may  come  within  a  few  weeks  after  inception,  either 
from  maniacal  exhaustion,  a  cerebral  seizure,  or 
decline  of  vital  powers,  or  it  may  be  prolonged;  some- 
times the  patient  is  relieved  by  weeks  of  comparative 
freedom  from  disease,  but  it  may  be  that  he  drags  out 
weary  months  of  continually  increasing  helplessness 
in  both  mind  and  body. 

A    CASE    OF    GENERAL    PARESIS    OF    LONG    DURATION. 

A.  B.,  get.  55,  merchant,  no  history  of  syphilis;  tem- 
perate ;  insanity  on  maternal  side  of  family.  The  family 
noticed,  ten  years  before  his   death,  that  his   speech  was 


238  GENERAL    PARESIS. 

clumsy  and  unintelligible,  his  walk  was  uncertain  and 
hands  unsteady.  He  made  expansive  statements  as  to  his 
business ;  showed  less  restraint  in  the  use  of  money ; 
became  very  social ;  showed  anxiety  for  nothing.  Two 
3'^ears  later,  a  diagnosis  of  paresis  was  made.  The  patient 
continued  in  business  and,  except  that  he  began  to  lose  in- 
terest in  his  affairs,  no  further  mental  symptoms  developed. 
Speech  was  jerky  and  scarcely  intelligible  ;  movements  of 
upper  and  lower  extremities  became  very  ataxic  so  that  he 
was  scarcely  able  to  feed  himself  or  walk  without  assistance. 
Examination  during  the  last  five  years  of  life  showed  ex- 
cessive tremor  of  tongue  and  muscles  of  face  ;  ataxia  and 
tremor  of  arms  with  ataxia  and  exaggerated  reflexes  in  legs  ; 
pupils  normal ;  speech  more  unintelligible  ;  had  maniacal 
and  epileptic  seizures  several  times  a  year.  (Abstract, 
Fisher,  E.  D.,  Journal  of  Nervous  and  Mental  Diseases, 
Vol.  18,  p.  824.) 

GENERAL    PARESIS    OF    LONG    DURATION. 

Savage  gives  a  case  of  general  paresis  of  long  dura- 
tion which  was  marked  by  severe  convulsions,  recurring 
during  the  greater  part  of  the  disease.  Death  occurred  at 
the  end  of  nine  years. 

A  CASE  OF  PARESIS  OF  FOURTEEN  YEARS'  DURATION. 

Brush  and  Sinkler  conjointly  report  a  case  of  gen- 
eral paresis  of  fourteen  years'  duration.  It  was  marked 
throughout  its  course  by  numerous  epileptiform  convulsions. 
(Abstract,  American  Journal  of  Insanity,  Vols.  45  and  46.) 

GENERAL    PARESIS    OF    LONG    DURATION. 

M.  Lapointe  observed  a  case  of  general  paralysis  of 
unusual  duration  in  which  the  cardinal  symptoms  had  grad- 
ually disappeared  and  had  been  replaced  by  simple  de- 
mentia. The  autopsy  verified  the  diagnosis  after  the  dis- 
ease had  lasted  fifteen  years.  (Abstract,  Journal  of  Ner- 
vous and  Mental  Diseases,  Vol.  24,  p.  314.) 


PROGNOSIS.  239 

A    CASE    OF    GENERAL    PARESIS    OF    LONG    DURATION. 

A  patient  who  had  general  paralysis  for  sixteen  years 
was  a  typical  case,  with  periodical  attacks  of  violence, 
sending  telegrams  continually,  writing  in  a  general  par- 
alytic style.  (Abstract,  Briscoe,  Journal  of  Mental  Sci- 
ences, Vol.  53,  p.  883.) 

A    CASE    OF    GENERAL    PARESIS    OF    LONG    DURATION. 

Lapointe  related  a  case  of  general  paresis  lasting  for 
twent3'-iive  years,  the  diagnosis  being  eventually  con- 
firmed by  post-mortem  examination.  (Abstract,  Journal 
of  Mental  Science,  Vol.  43,  p.  383.) 

A    CASE    OF    GENERAL    PARESIS    WITH    A    LONG    PRO- 
DROMAL   PERIOD. 

A  baronet,  who  had  shown  symptoms  of  brain  affection 
and  epileptiform  attacks,  so  far  back  as  1856,  lived  until 
1883.     (Abstract,  Blandford,  of.  ciL,  p.  299.) 

Prognosis. — The  prognosis  is  uniformly  unfavorable. 
It  is  regjarded  as  one  of  the  most  fatal  of  diseases. 
According  to  Ziehlen  some  years  ago  there  were  but 
a  dozen  cases  of  recovery  on  record.  Spitzka  gives 
an  account  of  one,  a  rheumatic  patient  whom  he 
treated  five  years  after  his  discharge,  and  was  unable 
to  find  any  trace  of  general  paresis  in  him.  Another 
instance  he  records  of  a  general  paretic  in  Australia, 
who  had  escaped  from  the  asylum,  and  five  years 
later  paid  them  a  visit  to  show  that  he  had  recovered. 
Other  authors  report  a  few  cases  whose  histories  were 
followed  for  from  six  to  ten  years  after  discharge  and 
no  relapse  had  occurred,  but  one  of  these  same  authors 
expresses  his  doubt  as  to  their  having  been  genuine 
cases.  It  is  the  opinion  of  some  writers  that  these 
and  similar  ones  were  not  cases  of  true  recovery. 
When  death  comes  within  two  or  three  years  after 
discharge  the  belief  by  them  is  that  the  patient  dies 


240  GENERAL    PARESIS. 

in  a  period  of  remission,  and  had  he  lived  a  little 
longer  the  disease  would  inevitably  have  returned, 
for  from  its  nature  it  is  necessarily  progressive  and 
fatal.  Blandford  says,  "  patients  are  dying  of  it 
(paresis)  in  all  the  as3'lums  by  the  hundred  3'et  the 
best  authorities  record  no  recoveries."  A  few  cases 
of  severe  injury,  or  intercurrent  disease,  have  been 
known  to  cause  a  form  of  recovery  but  it  is  after  all 
only  an  arrest  of  the  progressive  enfeeblement,  and 
the  mental  defect  in  time  goes  on.  Remissions  offer 
a  ground  of  hope,  but  in  a  great  number  of  cases  they 
are  rare,  and  after  each  remission  the  disease  re- 
appears in  a  more  intense  form.  General  paresis  is 
thus  far  one  of  the  most  unfavorable  forms  of  insanity 
as  regards  recovery  and  the  duration  of  life. 

SUPPOSED    RECOVERY. 

Simon  cites  the  case  of  a  patient  who  had  a  remission 
and  remained  well  for  twenty-five  j^ears. 

A    CASE    OF    GENERAL   PARESIS    WITH    MARKED    REMISSION, 
AFTER    SUPPURATION    THAT    RESEMBLED    A    RECOVERY. 

D.  Mc,  married,  get.  50,  railway  agent,  no  insane  in- 
heritance, the  first  attack  of  insanity  requiring  seclusion, 
although  he  had  been  peculiar  for  years  before.  Cause, 
over- work  ;  sober,  industrious  ;  no  syphilis  ;  first  symptoms 
were  excitement,  incoherent,  rambling  conversation,  exalted 
ideas  of  wealth  and  station  ;  benevolent,  thought  he  had  a 
secret  which  would  benefit  the  human  race.  On  admission 
he  talked  incessantly,  with  wild  exaltation  ;  he  was  sleepless, 
haggard,  restless,  and  unable  to  stand  still  for  a  minute. 
He  was  treated  with  hyoscyamine  without  benefit,  was  in- 
coherent ;  left  pupil  large  ;  speech  hesitating ;  took  several 
hours  to  finish  a  short  letter;  wet  and  dirty  at  times,  mem- 
ory became  worse.  In  three  months  he  had  a  huge  car- 
buncle on  back  of  his  neck  ;  no  sugar  in  his  urine.  After 
the  carbuncle,  his  symptoms  improved.    He  was  discharged 


TERMINATION.  241 

well  in  five  months'  time.  Some  months  later,  he  was  al- 
lowed to  manage  his  own  affairs.  He  is  now  under  treat- 
ment for  anomalous  parah'tic  symptoms,  supposed  to  be 
due  to  syphilis,  but  is  without  mental  disorder  four  years 
after  discharge.     (Abstract,  Savage,  o^.  cit.^  p.  322.) 

APPARENT     RECOVERY     FOLLOWING     EXCESSIVE 
SUPPURATION. 

In  the  only  case  of  general  paralysis  that  Savage  says 
he  ever  saw,  which  apparently  recovered,  one  symptom 
— cranial  nerve  paralysis — pointed  to  syphilis,  though  there 
was  no  other  proof  of  the  disease.  The  man  got  well 
and  remained  well  for  years,  but  died  of  obscure  nervous 
disease,  which  was  looked  upon  as  specific.  In  another 
case  with  specific  history  prolonged  remission  has  occurred 
and  in  both  of  these  cases,  excessive  suppuration  was 
the  immediate  cause  of  relief.  (Abstract,  Savage,  of.  cit., 
p.   322.) 

A     CASE     OF     PARESIS     WHICH     PRACTICALLY     RECOVERED. 

A  patient  with  typical  S3'mptoms  of  general  paralysis, 
after  six  or  eight  months'  treatment,  was  discharged  on 
leave.  After  a  year's  leave  of  absence  he  was  in  command 
of  a  ship  and  his  former  employers  could  detect  no  loss 
whatever  of  his  faculties.  (Abstract,  Savage,  loc.  cit.^ 
Vol.  5,  p.  402.) 

APPARENT    RECOVERY    FOLLOWING    A   CEREBRAL    SEIZURE. 

Recovery  occurred  after  an  apoplectiform  attack  in  a 
case  of  Schules.     (Abstract,  Spitzka,  of.  cit.,  p.  216.) 

Termination. — Death  may  come  in  one  of  many 
forms  to  terminate  the  course  of  the  disease.  It  may 
com.e  suddenly,  in  an  apoplectiform  or  an  epileptoid 
seizure,  in  paralysis  of  the  heart,  or  even  in  choking, 
or  the  end  may  be  hastened  by  tuberculosis,  pneu- 
monitis, edema  of  lungs,  acute  intestinal,  renal  or 
vesical    troubles,   deep    bed-sores,    septic    infection. 


242  GENERAL    PARESIS. 

or  by    embolism,    erysipelas,   phlegmon,  suicide    or 
trauma. 

Extended  dementia,  or  the  alternating  form  of 
paresis,  may  prolong  the  duration,  and  the  end  come, 
finally,  from  simple  exhaustion  due  to  the  general 
disease.  Cases  strongly  hereditary  run  a  longer 
course,  and,  as  has  been  said,  remissions  sometimes 
postpone  for  years  the  fatal  termination.  "  The  dis- 
ease is  special,"  says  Savage,  "  in  so  far  that  it  ends 
fatally  in  nearly  all  cases,  and  in  almost  always  the 
same  way;  and  that,  whatever  the  earlier  symptoms 
may  have  been,  the  later  ones  are  similar  to  a  re- 
markable degree." 

GENERAL    PARESIS,  DEATH    IN    THE    MANIACAL    STAGE  ; 
DURATION    ABOUT    A    YEAR. 

F.  C,  aet.  40.  Surgeon  in  Indian  army;  was  in  the 
massacre  of  Cawnpore,  escaped  and  underwent  many  risks 
and  hardships.  Some  time  afterwards,  his  friends  wrote 
that  he  was  much  altered  in  behavior,  subsequently,  that  he 
had  a  sunstroke.  Ten  3'ears  later  and  a  year  before  admis- 
sion he  was  induced  to  come  to  England  ;  on  the  voyage  he 
behaved  curiousl}'^ ;  also,  his  wife  died,  an  event  which 
seemed  to  excite  him  very  much,  and  his  behavior  called 
for  the  interposition  of  the  ship's  authorities.  On  his  arri- 
val, his  youngest  child  died.  At  home,  he  would  carry  his 
children  around  on  his  hip  in  the  Indian  fashion,  calling 
on  acquaintances  and  talking  in  an  excited  manner ;  he  be- 
haved strangely  to  his  mother's  servants,  whom  he  alarmed. 
He  invited  women  whom  he  met  at  night  into  his  mother's 
house.  Condition  on  admission  :  Five  feet  ten  inches  high, 
defective  vision,  some  obliquity  of  the  balls,  and  amaurosis 
of  left  eye  ;  dark  complexion  ;  he  has  hemorrhoids  and  is 
subject  to  prolapsus  ;  good  pulse,  no  difficulties  of  digestion 
or  chest  signs.  He  talks  incessantly  about  himself,  his  plans 
which  he  continually  changes ;  he  talks  to  everyone  he 
meets,  to  his  servants  of  his  own  affairs,  which  are  of 
Utopian  character ;  he  has  marked  elation  of  spirits  and 


TERMINATION.  243 

feebleness  of  intellect ;  he  talks  much  about  marrving, 
thinks  every  woman  he  sees  would  exactly  suit  him  and  has 
made  several  proposals  ;  he  will  extol  and  abuse  the  same 
person  in  the  same  breath.  Expression,  sleek  ;  facial  mus- 
cles relaxed ;  at  first  he  refused  to  leave  his  home  and 
became  excited  and  angry,  then  came  voluntarilv  and  was 
easily  persuaded.  After  arrival,  he  soon  made  himself  at 
home,  soon  found  occupation ;  he  groomed  his  own  horse, 
was  agreeable  and  sociable  but  talked  continually  of  his 
skill  and  reputation  and  wealth  ;  he  is  very  close  in  spend- 
ing his  money,  which  is  his  normal  character.  After 
three  months  :  Mental  characteristics  the  same,  less  excite- 
ment, a  total  absence  of  reticence.  Occasionallv  he  slurs 
in  speech,  eats  largely,  reads  novels  chiefly,  and  repeats 
the  incidents  to  everyone.  After  six  months  :  Health  con- 
tinues good,  stammers  rather  more,  mind  weaker  ;  he  is  full 
of  a  plan  to  make  his  escape  and  tells  everyone  about  it; 
he  eats  enormously,  rides  and  drives  out  dailv.  Eight 
months  :  He  went  into  a  public  house  leaving  his  horse 
with  the  attendant  and  bolted  across  the  fields  :  he  was 
found  at  his  mother's,  and  brought  back  ;  mind  more  fee- 
ble ;  he  made  offers  of  marriage  to  two  ladies  in  the  pres- 
ence of  both.  He  writes  numerous  letters  which  are  less 
connected  in  matter.  Tenth  month  :  He  is  more  restless 
and  irritable,  more  feeble,  talks  more  of  his  great  wealth 
and  schemes  ;  he  was  discovered  concealing  a  pair  of  boots  ; 
his  speech  is  more  affected,  with  increasing  difficulty  in 
pronouncing  the  labials.  Ten  and  a  half  months  :  After 
a  bad  night,  he  was  excited  early  in  the  morning.  Ex- 
citement continued  during  the  next  day ;  he  again  broke 
out,  tore  down  the  shutters  in  the  night,  threatened  to  mur- 
der the  first  person  who  came  near  him ;  he  is  highly 
ecstatic,  very  libidinous  and  elated,  says  he  will  be  Em- 
peror, that  he  will  marry  the  Queen,  and  fifty  other  women. 
Motor  difficulties  well  marked,  articulation  mumbling ; 
next  day  he  was  calmer.  Five  days  after  the  outbreak, 
he  has  continued  excited  and  at  times  raves,  talks  inco- 
herently, and  imagines  himself  in  communication  with 
God,  whom  he  addresses  in  a  familiar  conversational  way  ; 


244  GENERAL    PARESIS. 

he  takes  food  well,  but  sometimes  pours  his  soup,  wine 
or  medicine  on  his  head.  He  does  not  exhibit  so  much 
sexual  excitement,  motor  symptoms  continue.  February 
5th,  weakness  increased ;  he  complained  in  the  evening 
of  a  sore  throat  and  asked  to  have  it  examined,  but  spoke 
with  a  firm  voice  ;  shortly  after,  his  powers  quickly  failed 
and  he  died  from  exhaustion.     (Abstract,  Sankey,  o^.  cit.^ 

P-  319-) 

A    CASE    OF     GENERAL     PARESIS    WITH    A    PERIOD     OF    COM- 
PLETE   REMISSION. THE     DISEASE    RETURNED    AND 

CONTINUED    TO    A    FATAL    TERMINATION. 

Henry  J.  C,  single,  aet.  29  ;  has  one  sister  insane.  The 
cause  of  present  attack  unknown  ;  he  has  been  a  commer- 
cial traveller,  intemperate,  and  worked  very  hard.  The 
first  symptoms  appeared  in  August;  he  began  to  mope, 
and  felt  unable  to  do  his  work  ;  he  ate  well,  but  slept  badly. 
After  the  period  of  depression,  he  became  emotional,  excit- 
able and  threatening,  also  extravagant  and  generous  ;  sleep 
became  profound ;  he  indulged  sexually  to  a  great  extent ; 
thought  he  was  Christ.  On  admission  was  maniacal, 
dirty  and  destructive.  An  abscess  hard  to  heal,  con- 
taining gummous  unhealthy  looking  pus,  formed  on  his 
leg.  Narcotics  and  sedatives  had  no  effect  until  the 
period  of  excitement  passed  off  of  its  own  accord  after 
severe  purging  and  vomiting.  In  July,  a  year,  he  was 
reported  convalescing  ;  in  two  months  he  was  sent  on  leave  ; 
the  leave  was  extended  until  November,  when  he  was  dis- 
charged. He  had  not  recognized  the  fact  that  he  had  been 
excessively  violent  and  dangerous.  He  was  re-admitted  in 
September  two  years  ;  he  had  been  hard  at  work  for  a  year, 
and  had  suddenly  become  extravagant,  restless,  and  had 
ideas  of  grandeur.  On  admission  it  was  found  that  his 
speech  was  greatly  affected  ;  he  talked  freely  of  his  mil- 
lions, and  he  was  grand,  benevolent,  and  demonstrative. 
At  the  beginning  of  the  next  year  he  lost  strength  and 
flesh,  but  no  physical  disease  could  be  detected.  Early  in 
February,  he  wet  his  bed  and  had  an  epileptic  fit  marked 


TERMINATION.  245 

by  half-open  eyelids  and  lip  muscles,  inversion  of  right 
thumb,  clonic  convulsions  of  hands  and  feet ;  pupils  minute, 
right  the  larger,  and  temperature  98°.  In  the  evening  of 
the  same  day,  the  fits  returned,  affecting  both  extremities ; 
breathing  was  rapid,  skin  sweating ;  temperature  108°. 5  ; 
he  then  died.     (Abstract,  Savage,  o^.  cit.^  p.  304.) 


CHAPTER   XVII. 

PATHOLOGY  AND  PATHOLOGICAL  ANATOMY. 

Pathological  Anatomy. 
(<-?)   Macroscopic. 

The  Brain. — The  bone  of  the  calvarium  is  in  a  pro- 
portionate number  of  cases,  one  third  in  the  large 
series  observed  by  Mickle,  increased  in  thickness  and 
density,  with  disappearance  of  the  diploe.  In  a  much 
less  number  it  is  thinner  than  normal,  and  very  rarely 
it  is  abnormally  soft.  Often,  also,  the  bone  is  con- 
gested and  its  inner  surface  may  have  a  worm-eaten 
appearance.  Occasionally  there  may  be  a  distinct 
deposit  of  new  bone,  either  in  the  form  of  a  layer,  or 
of  one  or  more  exostoses,  on  the  inside  of  the  inner 
table. 

The  dura  is  frequently  thickened  and  vascular, 
sometimes  but  slightly.  According  to  Mickle  this 
change  is  found  in  about  one  half  the  cases.  In  a 
smaller  number,  one  fourth,  it  is  also  more  or  less 
tenaciously  adherent  to  the  bone,  between  which  also 
(dura  and  bone),  there  may  be  numerous  vascular 
connections,  consisting  of  thickened  and  tortuous 
vessels.  The  internal  surface  of  the  dura  often  shows 
evidences  of  internal  pachymeningitis,  usually  of  the 
hemorrhagic  variety.  This  may  be  evidenced  by 
either  the  existence  alone  of  the  characteristic  false 
membrane  and  reddish-brown  stainings,  which  mark 
the  seat  of  previous  hemorrhages,  or  more  rarely,  in 
addition  marked  hematomata,  which  may  be  present 

either  externally,  or  internally,  or  both. 

246 


THE    BRAIN.  '  247 

In  the  subdural  space  there  is  an  increase  of  cere- 
brospinal fluid,  which  may  be  either  pellucid  or 
turbid.  The  arachnoid  is  always  more  opaque  and 
usually  is  much  thicker  and  tougher  than  normal,  and 
either  mottled  with  white  spots,  or  striated  along  the 
fissures  with  white  fibrous  appearing  bands.  These 
changes  are  more  marked  over  the  fi-onto-parietal  con- 
vexity and  internal  surface  of  the  hemispheres,  and 
often  the  interpeduncular  space  is  bridged  by  a  tough 
thickened  arachnoid.  Calcareous  plates  are  occasion- 
ally found  in  the  membrane. 

Under  the  arachnoid,  especially  over  the  fronto- 
parietal regions  of  the  brain,  are  seen  covering  the  pia 
numerous  varying  sized  dilated  and  congested  vessels, 
13'ing  in  what  appears  like  a  milky  or  opaque  jelly;  if 
the  arachnoid  is  perforated  this  material  oozes  out  as 
a  dirty  opaque  fluid.  The  pia  is  greatly  thickened 
and  may  occasionally  contain,  either  small  bony 
plates,  firm,  fibrous,  whitish  nodules,  or  a  few  patches 
of  lymph  or  pus.  When  the  membrane  is  removed 
from  the  brain  substance  an  intense  edematous  con- 
dition is  found  everywhere  present,  both  in  the  fissures 
and  over  the  surface  of  the  convolutions  and  per- 
meating the  cortical  substance.  The  membrane  no 
longer  readily  separates  from  the  brain  cortex,  but  is 
adherent  to  it,  especially  over  the  apices  of  the  con- 
volutions, and  the  attempt  at  removal  brings  away 
also  bits  of  the  adherent  cortex.  These  changes  are 
well  shown  in  Plate  XII.  The  lobes  of  the  brain,  also, 
often  are  adherent  one  to  the  other,  such  cohesion 
being  especially  common  between  the  frontal  lobes. 

In  very  acute  cases  these  cerebro-meningeal  adhes- 
ions may  be  absent  and  the  meningeal  changes  con- 
sist of  a  slighth"  opaque  arachnoid,  an  edematous 
and  congested  pia.  In  such  cases  the  brain  may 
appear  to  be  increased  in  volume,  owing  to  the  intense 


248     PATHOLOGY  AND  PATHOi^UlilCAL  ANATOMY. 

congestion  and  edema  and,  if  the  dura  is  removed,  it 
may  be  impossible,  owing  to  the  projecting  brain,  to 
replace  the  calvaria.  These  changes,  instead  of 
involving  entire  lobes,  may  be  confined  to  isolated 
areas. 

In  the  more  chronic  forms,  which  are  the  more 
common,  the  brain  is  more  or  less  flaccid,  smaller 
and  lighter  than  normal.  The  appearance  of  the 
brain  cortex  varies,  the  changes  being  most  pro- 
nounced in  the  frontal  res^ion  and  shadino^  ofl'  tjradu- 
ally  toward  the  normal,  as  we  pass  backward.  The 
one  practically  constant  feature,  ninety-four  per  cent, 
in  Mickle's  series,  being  that  it  is  much  reduced  in 
thickness.  The  convolutions  are  also  thin,  shrivelled, 
or  flattened.  It  may  be  softer,  either  in  whole  or  in 
parts  only,  more  rarely  it  is  indurated,  either  in  small 
areas,  or  diflusely,  when  it  gradually  shades  oft'  to 
normal,  or  to  lessened  consistence  as  we  examine 
from  the  frontal  towards  the  occipital  region.  Usu- 
ally it  is  the  seat  of  areas  of  hyperemia  of  more  or 
less  irregular  distribution,  but  may  be  anemic.  In 
the  former  case  its  color  would  be  reddish,  in  various 
degrees,  or  mottled,  while  in  the  latter  it  is  either 
pale,  fawn  color,  dirty  white,  or  slate  colored.  The 
strata  are  often  indistinct. 

The  cortex  is  found  hyperemic  and  softened  in  cases 
of  comparatively  brief  duration,  the  longer  the  course 
of  the  disease  the  more  apt  we  are  to  find  it  indurated 
and  anemic;  some  authorities,  Clouston  and  Berkley 
among  others,  describe  the  latter  as  the  condition 
more  commonl}'  met  with.  Where  the  pia  has  been 
adherent  the  convolutions  present  an  irregularly 
eroded  appearance;  as  Clouston  expresses  it,  they 
resemble  the  surface  of  a  cheese  where  a  mouse  has 
been.  This  tearing  oft'  of  the  cortex  has  been  termed 
decortication.     The  erosions  may  be  red  in  color,  or 


Plate  XIL 


APPEARANCE  OF  PORTION  OF  VERTEX  OF  THE  BRAIN  IN  ADVANCED 
PARESIS.     (Clouston.) 

a.  Skull-cap  condensed,  b.  Anterior  third,  showing  thickened  milky  arachnoid,  dotted 
over  with  small  white  spots,  with  tortuous  dilated  vessels,  and  turbid  fluid  beneath, 
c,  Middle  third,  showing  the  appearance  after  pia  has  been  removed.  The  outer 
layers  of  gray  matter  have  been  torn  away  in  irregular  patches,  adhering  to  the 
pia  and  removed  with  it.  The  parts  so  removed  have  left  ragged  eroded-looking 
spaces,  d.  The  pia  stripped  from  middle  third,  concealing  posterior  lobe,  and  showing 
the  appearance  of  its  inner  surface  with  portions  of  the  convolutions  adhering  to 
it.  It  is  a  tough,  thick,  spongy-looking  texture,  instead  of  the  normal  delicate, 
filmy,  transparent  membrane. 


THE    BRAIN.  249 

pale,  according  to  the  progress  of  the  disease.  They 
are  most  common  in  the  frontal  and  parietal  lobes 
and  the  gyri  about  the  olfactory  bulbs  at  the  base,  but 
may  occur  elsewhere.  Mickle  claims  that  they  do 
not  always  correspond  to  the  adhesions  on  the  sum- 
mits of  the  gyri,  but  may  be  found  at  the  bottom  of 
the  fissures.  Sometimes  the  entire  depth  of  the  gray 
matter  comes  off,  leaving  the  white  matter  beneath. 
Decortication  in  greater  or  less  degree,  is  the  most 
characteristic  and  frequent  of  the  gross  lesions  of 
paresis,  but  is  not  pathognomonic. 

The  white  matter,  as  the  gray,  may  be  either  of 
diminished  consistence,  when  it  is  hyperemic  and 
reddish,  or  mottled  in  color;  or  of  increased  consist- 
ence, when  it  is  of  an  unnatural  whiteness  and  may 
display  a  sieve-like  appearance.  The  ventricles  are 
dilated,  filled  with  fluid  and  the  ependyma  is  thick- 
ened, roughened  and  tougher  than  normal.  In  marked 
cases  it  is  covered  with  granulations  and  feels  dis- 
tinctly rough  to  the  touch.  This  condition  is  usually 
most  marked  in  the  floor  of  the  fourth  ventricle  and 
there  it  often  presents  a  grayish  gelatinous  appearance. 

The  ganglia  at  the  base  of  the  brain  are  often  atro- 
phied  and  they  may  be  either  softer  or  harder  than 
normal.  The  pons  and  medulla-^  niay  also  in  some 
cases  be  the  seat  of  morbid  changes,  either  softening 
or  induration  being  present,  more  rarely  distinct 
atrophy  may  be  seen. 

Similar  changes  are  sometimes  found  in  the  cere- 
bellum. Mickle  claims  to  have  found  adhesions  ol 
the  membranes  to  the  cerebellum  in  forty-four  per 
cent,  of  his  cases.  Other  writers  deny  that  cerebellar 
adhesions  occur. 

1  That  the  pons  and  medulla  are  anatomicalh'  parts  of  the  spinal  cord  is 
believed  by  the  writer,  but  as  in  most  text-books  they  are  considered  as 
parts  of  the  brain,  they  are  here  so  included  and  will  be,  also,  when  the 
microscopic  changes  are  described. 


250  PATHOLOGY  AND  PATHOLOGICAL  ANATOMY. 

The  olfactory  bulbs  and  tracts  are  often  atrophied 
and  softened,  and  similar  changes  have  been  found  in 
the  optic  nerves. 

The  prominent  macroscopic  changes  in  the  brain 
and  its  membranes  may  be  summed  up  as  follows : 

1.  Thickening  of  the  dura,  with  internal  hemor- 
rhagic pachymeningitis  (about  fifty  per  cent,  of  the 
cases). 

2.  An  increase  of  the  fluid  in  the  subdural  space 
and  meshes  of  the  arachnoid. 

3.  Opacity  and  thickening  of  the  pia  with  adhe- 
sions to  the  cortex,  causing  portions  of  the  cortex  to 
adhere  to  the  membrane,  when  it  is  stripped  off 
(decortication). 

4.  General  flaccidity  and  diminution  of  the  weight 
of  the  brain  and  marked  narrowing  of  the  cortex. 

5.  Areas  of  softening  and  hyperemia  and  of  undue 
firmness  and  anemia  scattered  over  the  cortex. 

6.  Dilatation  of  the  ventricles,  thickening  and 
roughening  of  the  ependyma  and  increase  of  fluid 
within  them. 

The  Spinal  Cord. — As  has  been  noted  in  discussing 
symptomatology,  the  prominence  of  spinal  symptoms 
varies.  In  those  cases  in  which  they  are  slight,  the 
morbid  anatomical  changes  present  are  slight,  in 
those  in  which  they  are  prominent,  the  changes  in 
the  cord  and  its  membranes  are  likewise  prominent. 
Alterations  of  some  sort  are  found  in  most  cases. 
The  following  changes  may  be  present.  The  men- 
inges are  often  thickened  and  h3'peremic,  opaque, 
granulated  and  adherent  to  each  other  and  to  the 
cord.  These  appearances  are  more  apt  to  be  found 
posteriorly.  In  a  small  number  of  cases  evidences 
of  hemorrhagic  pach3'meningitis,  in  the  shape  of  re- 
cent or  old  clots,  may  be  found.  Clots  are  some- 
times also  found  extra-dural. 


THE    BRAIN.  25 1 

The  thickened  pia  surrounds  the  spinal  nerves  as 
they  emerge,  forming,  as  Mickle  expresses  it,  muffs 
for  them. 

In  acute  cases  the  spinal  membranes  may  be  red- 
dened, thickened,  somewhat  opaque  and  markedly 
edematous. 

Mickle  found  in  two  thirds  of  his  cases  softening 
of  parts  of  the  cord;  in  one  third,  he  found  induration 
and  in  from  ten  to  twelve  per  cent,  atrophy.  Either 
hyperemia,  or  pallor  of  the  cord  substance,  may  be 
found  in  a  few  cases. 

In  a"^considerable  number  of  cases,  15.9  per  cent, 
according  to  Bevan  Lewis,  sclerosis  of  the  posterior 
columns  and  of  the  dorsal  and  lumbar  posterior  nerve 
roots,  with  thickening  of  their  sheaths,  similar  to  that 
in  tabes,  is  found.  When  found,  the  sclerosis  is  usu- 
ally most  marked  in  the  lower  part  of  the  cord, 
becoming  narrower  and  more  confined  to  the  columns 
of  Goll  as  it  ascends,  to  cease  at  the  floor  of  the 
fourth  ventricle.  In  other  cases  the  sclerosis  is  con- 
fined to  the  posterior  commissural  zone  and  the  pos- 
terior median  columns  (columns  of  Goll),  the  root 
zones  escaping. ' 

More  rarely  a  secondary  descending  degeneration 
of  the  pyramidal  tracts  occurs  either  alone,  or  asso- 
ciated with  the  posterior  sclerosis.  Either  a  diffuse 
slight  sclerosis,  causing  generally  increased  hardness, 
or  a  slight  diffuse  myelitis,  causing  general  softening, 
may  be  occasionally  present.  Atrophy  of  parts  of 
the  gray  matter,  especially  the  horns,  is  sometimes 
present. 

(d)  Microscopic. 

The  Brain. — The  microscopic  changes  found  in  gen- 
eral paresis  are  manifold ;  none  however  are  strictly 
characteristic   of  the   disease   and  it  is  doubtful  if  it 


252  PATHOLOGY  AND  PATHOLOGICAL  ANATOMY. 

can  positively  be  diagnosed  with  the  microscope.^ 
The  main  interest,  of  course,  attaches  to  those  found 
in  the  pia  and  cortex.  These  changes  may  be  classi- 
fied as  follows: 

1.  Those  in  the  blood-vessels  of  the  cortex  and 
pia,  and  the  perivascular  or  13'mph-spaces. 

2.  The  neuroglia. 

3.  The  nerve  cells  and  fibers. 

I.  The  Blood-Vessels. — The  walls  of  the  capillaries 
are  thickened  and  present  a  granular  appearance,  with 
an  increase  in  the  number  of  nuclei  that  are  normally 
present  there.  (See  Plate  XIII.,  Fig.  2.)  Fre- 
quently there  is  some  migration  of  leucoc3'tes,  which 
are  found  in  the  perivascular  spaces. 

The  adventitia  of  man}^  of  the  pial  and  intra- 
cerebral arterioles  is,  according  to  the  state  of  the 
disease,  infiltrated  more  or  less  densely  with  small 
round  cells,  which  in  marked  examples  are  found 
also  in  the  neighboring  nervous  tissues.  In  advanced 
cases  the  cells  may  be  so  dense  that  the  vessel  wall  is 
hidden;  indeed,  Mickle  has  compared  the  appearance 
to  that  of  a  muft'  surrounding  the  vessel.  This  infil- 
tration is  probably  due  to  a  periarteritis.  (Plate 
XIII.,  Fig.  3.) 

The  perivascular,  or  lymph  spaces  finally  become 
full  of  these  cells,  so  that  finally  many  of  them  become 
impervious  to  the  passage  of  the  lymph.  Hematoidin 
and  cellular  debris  are  also  found  in  these  spaces. 
Some,  owing  to  the  pressure  of  the  fiuid  in  attempt- 
ing to  get  through,  are  dilated. 

In  addition  to  the  vessels  so  affected  W.  Ford 
Robertson^  lays  stress  upon  the  large  numbers  of 
capillaries  and  arterioles  that  are  aflfected  with  that 
form  of  degeneration  known  as  hyaline  fibroid  degen- 

1  V/de  O.  Schmidt,  Allgemeine  Zeitschrift  fiir  Psvchiatrie,  54,  1897- 
1898,  p.  178. 

2 Pathology  of  Mental  Diseases,  p.  140  et  seq. 


THE    NEUROGLIA.  253 

eration,  or  arterio-capillary  fibrosis;  this,  while  present 
to  a  greater  or  less  extent  in  all  persons  after  middle 
life,  is  especially  prominent  in  cases  dying  of  general 
paresis.  It  is  characterized  by  the  proliferation  of 
the  endothelial  cells,  the  formation  of  new  fibrous 
tissue,  and  finally  by  a  hyaline  degeneration  of  these 
cells  and  fibers,  causing  the  vessel  to  present  a  thick- 
ened, vitreous  appearance. 

In  the  arterioles  and  venules  affected  with  this  form 
of  degeneration  the  adventitia  is  converted  into  a 
broad,  homogeneous  band  of  regular  outline.  In 
these  vessels  there  is  also  usually  some  degeneration 
of  the  middle  coat.  The  short  vessels  of  the  first 
layer  of  the  cortex  are  particularly  affected. 

Other  vascular  changes,  not  so  commonly  met 
with,  are  pigmentation  of  the  vessel  walls;  dilatation 
of  the  vessel;   obliteration  or  narrowing  of  the  lumen. 

2.  The  Neuroglia. — Those  elements  of  the  neuroglia 
known  as  Deiters',  or  spider  cells  present  marked 
changes  in  the  affection  that  we  are  considering. 
Bevan  Lewis  ^  terms  these  cells  and  their  processes 
the  "  lymph  connective  tissue  of  the  brain  "  and  first 
advanced  the  view  that  they  play  some  part  in  "  the 
reabsorption  and  distribution  of  the  effete  material 
and  surplus  plasma."  By  means  of  methods  de- 
veloped by  him,  it  is  found  that  these  cells  throw  off 
two  sets  of  processes:  (i)  "An  enormous  number 
of  extremely  delicate  fibers,  which  spread  into  the 
intervascular  area  around,  and  (2)  a  much  thicker, 
coarser  process,  which  often,  after  a  tortuous  course, 
ends  in  the  adventitial  sheath  of  the  blood-vessel." 
(See  Fig.  4.)  These  processes,  in  crossing  the 
perivascular  canal,  give  off  a  number  of  delicate  proc- 
esses  that    traverse    the    canal.      This    view   of  the 

1  Mental  Diseases,  2d  Edition,  p.  98  et  seq. 


254     PATHOLOGY  AND  PATHOLOGICAL  ANATOMY. 


Swollen  deoenerated 
Nerve-cell. 


Vascular  process 
of  Spider-cell 


Spinous  extensions  from 
vascular  walls. 


Oegeneratlng  Nervs- 

cells  attacked  by 

Spider-cens. 


Spider-cell  with  Its 
vascular  process. 


Arteriole  surrounded  by 
Spider  element*. 


DEGENERATION  OF  NERVE-CELLS  IN  CORTEX 
WITH  PROLIFERATION  OF  THE  SPIDER  OR  SCAV- 
ENGER-CELLS. SECTION  FROM  FIFTH  CORTICAL 
LAYER  OR  MOTOR  REGION. 

X  210.     (BEVAN  LEWIS.) 


THE    NERVE    CELL.  255 

function  of  these  cells  has  been  accepted  by  other, 
but  not  by  all  pathologists. 

In  general  paresis  there  is  a  general  hypertrophy  of 
this  system,  the  cell  body  becomes  considerably  en- 
larged, often  exhibiting  subdivisions  of  the  nucleus, 
and  stains  much  more  deeply  with  aniline  than  does 
the  normal  cell.-'^  The  processes  also  stain  deeply 
and  the  vascular  processes,  which  stain  still  more 
deeply  (those  attached  to  the  blood-vessels),  are  in- 
creased in  size  and  often  in  number  and  are  seen  to 
be  attached  to  the  vessel  b}'  a  nucleated  mass  of 
protoplasm.  The  other  processes  are  often  seen  to 
surround  and  embrace  the  nerve  cells.  (See  Fig. 
4.)  These  changes  occur  in  the  later  stages  after 
the  perivascular  spaces  have  become  blocked  up, 
(see  p.  252)  and  it  is  proper  to  state  are  not  always 
found  markedly  developed.  In  a  series  of  sixty-four 
cases,  examined  by  Ford  Robertson,  only  one  third 
showed  them  to  a  great  degree.  According  to  Bevan 
Lewis  ^  they  are  due  probably  to  an  effort  of  these 
cells  to  remove  the  effete  materials  and  cellular 
debris  that  are  found  in  the  brain  from  degenerated 
nerve  cells,  and  whose  removal  is  hindered  by  the 
obstruction  of  the  perivascular  spaces  or  lymph  chan- 
nels.    He  often  speaks  of  them  as  "scavenger  cells." 

3.  The  Nerve  Cell. — Various  forms  of  degeneration 
of  the  neurone  are  met  with,  all  of  which  may  also  be 
found  in  other  conditions.  That  most  commonly  met 
with  is  the  pigmentary  or  yellow  globular.  Bevan 
Lewis  was  the  first  to  lay  stress  upon  this  form, 
which  he  termed  pigmentary  or  fuscous.  It  consists 
in  the  early  stages  of  the  formation  below  the  nucleus 
of  a  quantity  of  yellow  pigment;   at  this  time  also  the 

1  Normally  the  cell  body  and  processes,  i.  e.,  Deiters'  cells,  do  not  stain 
at  all  with  aniline,  the  nucleus  alone  staining  faintly. 
"^  Loc.  cit.,  p.  183. 


256  PATHOLOGY  AND  PATHOLOGICAL  ANATOMY. 

cell  body  becomes  swollen,  and  the  protoplasm  stains 
more  deeply  than  normally.  As  the  process  con- 
tinues the  amount  of  pigment  increases,  the  nucleus 
is  displaced  and  even  it  sometimes  becomes  pig- 
mented. The  protoplasm  stains  more  faintly  than  nor- 
mall}^  (chromatolysis)  and  the  processes  begin  to  dis- 
appear until  finally  none  are  left,  the  nucleus  disin- 
tegrates and  the  cell  becomes  a  mass  of  translucent 
colorless  finely  granular  material  that  practically 
does  not  stain  at  all.      (See  Plate  XIII.,  Fig.  5.) 

Bevan  Lewis  believes  that  the  pigment  accumula- 
tion is  "  invariably  a  witness  of  bygone  functional 
activity "  and  that  its  increase  is  due  to  an  over- 
activity of  the  cell.  This  view  is  also  held  by 
Schafer,  but  is  combated  b}'  many  pathologists,  not- 
ably Marinesco  and  Robertson.  The  difierent  stages 
in  the  process  have  been  well  summarized  by  Bevan 
Lewis^  thus: 

Period  of  Over- Activity? — (i)  Swelling  of  cell 
with  increase  of  pigment.  (2)  Advancing  degenera- 
tion, cell  more  globose,  protoplasm  retracting.  Scle- 
rotic investment  of  cell  and  cincture  formed. 

Period  of  Diminished  Activity. — Nucleus  eccen- 
tric, deformed,  fatty,  with  narrow  encircling  zone  of 
protoplasm.  Processes  few;  these,  as  well  as  cell- 
protoplasm,  faintly  stained. 

Period  of  Absoi-ption. — Fatty  transformation  and 
decoloration  of  cell.  Atrophy  with  shrinking  or  rup- 
ture into  a  heap  of  granules. 

Agapofi',  who  examined  the  brains  of  six  cases  of 
general  paresis,  lays  stress  upon  the  number  of  the 

'  For  further  description  of  this  process  see  Mental  Diseases,  2d 
Edition,  Bevan  Lewis,  p.  527  et  seq.;  W.  Ford  Robertson,  Pathology  of 
Mental  Diseases,  p.  243  et  seq. 

*It  must  be  borne  in  mind,  as  has  been  before  stated,  that  many  pathol- 
ogists do  not  believe  in  the  existence  of  a  period  of  over-activity,  but 
that  the  entire  process  is  due  to  one  of  diminished  activity. 


THE    NERVE    CELL.  257 

pyramidal  cells  in  which  the  gemmiiles  of  the  den- 
dritic processes  were  either  lost  entirely,  or  were 
diminished  in  number.-^ 

There  is  also  disappearance  of  the  medullated  fibers 
in  portions,  principally  the  frontal  and  antero-parietal 
of  the  cerebral  cortex.  There  is  considerable  loss  of 
the  tangential  and  also  of  the  radial  fibers.  This  is 
but  a  natural  consequence  of  the  degeneration  of  the 
cell  bodies  above  described.  In  the  nerve  fibers  of 
the  white  matter  changes  are  also  found.  Patches 
and  streaks  of  gray  degeneration  were  found  in  the 
immediately  subcortical  substance  and  Tuczek  ob- 
served a  like  degeneration  in  the  fibers  between  the 
cortex  and  medulla,  which  sometimes  appeared  as  a 
gray  streak  or  stripe.  Similar  changes  mav  be  found 
in  the  corpus  callosum,  fornix,  septum  lucidum  and 
crura  cerebri.  In  the  optic  thalami,  corpora  striatse, 
pons,  medulla  and  cerebellum,  vascular  changes  and 
cell  degeneration,  similar  to  those  occurring  in  the 
cortex,  are  more  or  less  markedly  present. 

Degeneration  of  the  cells  constituting  the  bulbar 
nuclei  is  a  most  common  lesion.  Its  relationship 
with  many  of  the  characteristic  physical  symptoms, 
viz:  weakness  of  the  facial  muscles,  tongue,  etc.,  is 
apparent. 

The  important  microscopic  changes  in  the  brain 
may  be  summarized  as  follows :  An  increase  in  the 
number  of  nuclei  in  the  walls  of  the  capillaries  with 
a  thickening  and  granular  appearance  of  their  walls. 
A  more  or  less  intense  round-cell  infiltration  of  the 
adventitia  of  the  arterioles.  Blocking  up  of  the  peri- 
vascular, or  lymph,  spaces  with  leucocytes,  hema- 
toidin  and  cellular  debris,  with  here  and  there  dilata- 
tion of  these  spaces.     An  affection  of  other  vessels 

^Neurolog.  Centralblatt,  April  i,  1S99.  - 


258  PATHOLOGY  AND  PATHOLOGICAL  ANATOMY. 

with    that   form  of  degeneration  known  as   hyaline 
fibroid  degeneration,  or  arterio-capillary  fibrosis. 

A  marked  hypertrophy  and  increase  in  number  of 
those  elements  of  the  neuroglia,  known  as  Deiters' 
cells,  the  lymph  connective  tissue  of  Bcvan  Lewis, 
this  being  especially  marked  along  the  course  of  the 
blood-vessels.  Degeneration  of  the  nerve  cell,  the 
most  common  being  the  pigmentary  or  yellow  globular 
form  and  consequent  disappearance  of  nerve  fibers  in 
different  parts  of  the  brain. 

Spinal  Cord. — The  relationship  between  microscopic 
changes  found  in  the  cord  and  the  prominence  of 
spinal  S3'mptoms  is  identical  with  the  statement  made 
on  p.  250  in  describing  macroscopic  appearances. 
The  walls  of  the  blood-vessels,  especially  those  of  the 
posterior  columns,  are  thickened.  The  appearance, 
however,  usually  differs  from  that  of  the  cerebral 
vessels,  in  that  the  lumen  is  diminished  and  the  mus- 
cular coat  hypertrophied.  The  lymph  channels  are 
not  blocked  up  or  dilated,  and  there  is  no  nuclear 
proliferation.  Bevan  Lewis  looks  upon  this  change 
as  "  one  of  simple  compensatory  hypertrophy,  induced 
by  the  engorged  condition  of  these  vessels  demanding 
increased  contraction  on  the  part  of  the  arterial  muscle 
to  carry  on  the  circulation  of  the  cord."  The  spider, 
or  Deiters'  cells  also  hypertrophy  and  multiply,^  the 
proliferation  is  most  marked  along  the  course  of  the 
blood-vessels.  According  to  the  tracts  involved,  as 
outlined  in  the  description  of  the  macroscopic  changes 
on  p.  251,  the  microscopic  evidences  of  degeneration 
are  found,  i.  e.,  loss  or  swelling  of  the  myeline  of  the 
medullated  fibers,  or  a  granular  condition  of  it  with 
distortion  and  interruption  of  the  nerve  fibers.     They 

*  This  hypertrophy  is  also  found  in  chronic  inflammatory  and  other 
disorders  of  the  spinal  cord. 


SPINAL    CORD.  259 

are  usually  most  marked  in  the  posterior  columns,  in 
some  cases  resembling  in  character  and  distribution 
the  appearances  found  in  tabes,  in  others  the  root 
zones  escape. 

The  question  frequently  arises  concerning  the  rela- 
tionship between  general  paresis  and  tabes  dorsalis. 
It  seems  safe  to  say  that  the  opinion  of  most  neuro- 
pathologists is  that  they  are  the  same  disease.  As 
Dercum  has  expressed  it,  general  paresis  is  a  tabes  of 
the  brain.  Mills  also  believes  that  they  are  the  same 
process,  in  the  one  case  affecting  cerebral  neurones 
mainly,  in  the  other,  spinal,  while  in  a  smaller  group, 
both  sets  suffer  and  the  clinical  symptoms  of  general 
paresis  and  tabes  are  combined  (see  symptomatology). 
At  a  meeting  of  the  London  Pathological  Society,^  at 
which  most  of  the  prominent  English  neurologists 
and  neuro-pathologists  were  present,  this  subject  was 
discussed.  Mott,  who  opened  the  discussion,  held 
that  the  two  conditions  are  one  and  the  same  morbid 
process,  affecting  different  parts  of  the  nervous  system. 
This  view  was  concurred  in  by  most  of  those  present. 
Among  those  who  hold  similar  views  may  be  men- 
tioned Raymond,  Flechsig  and  Nageotte;  on  the 
other  hand  Ballet,  Joffroy,  Geil  and  Hoche  do  not 
believe  that  the  lesions  are  of  the  same  nature. 

Besides  the  variations  above  described  in  the  cord, 
we  find  in  other  cases  both  the  lateral  and  posterior 
columns  are  affected,  in  the  former  the  change  is 
usually  most  marked  in  the  dorso-lumbar  region. 
Rarely  degeneration  may  be  found  in  the  anterior 
columns,  alwa3^s,  however,  in  connection  with  dis- 
ease of  either  the  posterior  or  lateral  columns  or 
both.  Degeneration  of  the  cells  of  the  anterior  horns 
is  also  usually  more  or  less  prominent.^     More  or  less 

^Transactions  London  Pathological  Society,  1900,  11,  339. 
^Orr  &  Rows,  Brain,  1901,  p.  236. 


26o  PATHOLOGY  AND  PATHOLOGICAL  ANATOMY. 

degeneration  of  the  cells  in  the  posterior  root  ganglia 
may  also  be  found. 

The  Peripheral  Nerves.  —  Changes  in  these,  both 
cranial  and  spinal  are  also  found.  Dr.  Alfred  W. 
Campbell  ^  found  extensive  diseases  of  the  pncumo- 
gastric  and  less  extensive  diseases  of  the  phrenic 
nerves.  More  or  less  degeneration  of  the  optic 
nerves  may  occur.  The  nerve  libers  of  the  anterior 
nerve  roots  are  degenerated  and  the  connective  tissue 
is  increased.  These  changes  are  usually  most  marked 
in  the  lumbar  and  sacral  regions. 

The  mixed  spinal  nerves  also  show  evidences  of 
degeneration.  Campbell  says  this  is  a  mixture  of  a 
parenchymatous  degeneration  (degeneration  of  the 
medullary  sheath;  swelling  and  atrophy  of  the  axone), 
and  interstitial  inflammation  (overgrowth  of  the  con- 
nective tissue).  These  changes  are  most  marked  in 
the  nerves  forming  the  lumbar  and  sacral  plexuses. 
The  ganglia  of  the  S3'mpathetic  S3stem  sometimes 
show  evidences  of  degeneration  of  the  nerve  cells 
and  increase  of  connective  tissue. 

The  muscles  including  the  heart  and  diaphragm 
show  degenerative  changes,  become  fatt}',  and  show 
more  or  less  complete  disappearance  of  muscle  fibers, 
with  proliferations  and  increase  of  the  nuclei  of  the 
sarcolemma  and  connective  tissue.  The  number  of 
motor  end  plates  in  the  cases  examined  by  Campbell 
was  lessened  and  some  were  in  process  of  degenera- 
tion. 

Pathology.  —  The  starting  point,  whether  in  the 
blood-vessels  or  nerve  elements,  of  the  lesions  above 
described,  has  caused  much  discussion  and  able  ob- 
servers are  ranged  upon  each  side.     One  of  the  most 

^  Journal  of  Mental  Science,  April,  1894. 


PATHOLOGY.  26 1 

prominent  and  earnest  advocates  of  the  view  that  the 
primary  seat  of  the  lesions  is  the  blood-vessels  is 
Bevan  Lewis.""^  He  claims  that  there  are  three  stages 
in  the  development  of  the  morbid  changes,  viz: 

1.  A  stage  of  inflammatory  change  in  the  tunica 
adventitia  with  excessive  nuclear  proliferation,  pro- 
found changes  in  the  vascular  channels  and  trophic 
changes  induced  in  the  tissues  around. 

2.  A  stage  of  extraordinar}-  development  of  the 
lymph-connective  system  of  the  brain,  with  a  parallel 
degeneration  and  disappearance  of  nerve  elements^ 
the  axis-cylinders  of  which  are  denuded. 

3.  A  stage  of  general  fibrillation  with  shrinking, 
and  extreme  atroph}'  of  the  parts  involved. 

He  believes  that  this  is  an  irritative  process  of  the 
arterioles  of  the  pia  and  brain,  but  lays  no  stress  on 
the  changes  in  the  walls  of  the  capillaries. 

Berkley  also  advocates  the  view  that  the  blood- 
vessels are  the  primary  seat  of  the  lesions.  He  says '} 
"  While  it  cannot  yet  be  regarded  as  an  established 
fact  that  vascular  disease  precedes  all  cases  of  paretic 
dementia,  this  theory,  while  affording  a  ready  means 
to  account  for  the  pathological  etiology,  would  enable 
us  to  follow  out  the  various  steps  in  the  clinical 
picture  of  the  disease." 

"Thus,  the  first  stage,  that  of  mental  change  and 
irritability,  would  correspond  to  the  inception  of  the 
vascular  disease,  slight  proliferation  of  new  elements 
in  the  sheaths,  on  account  of  which  the  nutrient  serum 
finds  some  difficulty  in  finding  its  way  through  the 
thickened  arteriole-capillary  wall.  The  second  stage, 
that  of  active  delusion  and  motor  excitement,  would 
come  when  the  nuclear  proliferation,  dilatation  of  the 

^Mental  Diseases,  2d  ed.,  p,  552. 
*  Italics  author's. 
^Mental  Diseases,  p.  202. 


262  PATHOLOGY  AND  PATHOLOGICAL  ANATOMY. 

lymph  space,  and  filling  up  of  the  same  with  cells 
and  cellular  debris,  would  be  sufficient  to  dam  back 
into  the  brain  tissue  the  devitalized  serum,  inducing 
both  edema  and  cell  hunger  from  the  imperfect  circu- 
lation of  the  necessary  nutrient  fluid.  Many  of  the 
epileptiform  and  apoplectiform  crises,  no  cause  for 
which  can  be  found  in  the  naked-eye  examination, 
might  readily  be  due  to  the  plugging  of  the  perivas- 
cular lymph  channel,  either  temporarily  with  leuco- 
cytes, or  later  permanently  with  proliferated  round 
cells."  "  The  final  stage,  that  of  dementia,  would 
occur  only  when  the  arteries  are  profoundly  diseased, 
and  their  surrounding  canals  completely  obstructed 
by  the  cellular  overgrowth  and  accumulation  of 
debris  from  many  sources.  According  to  this  view 
the  degeneration  of  neurones  and  neuroglia  play  an 
entirel}^  secondary  part,  the  cell  atrophy  and  scler- 
oses of  the  tissue  following  the  lesions  of  the  blood- 
vessels." 

He  further  says  (^loc.  cit.,  p.  205):  "That  in  the 
very  earliest  obtainable  autopsies  the  protoplasmic 
alterations  found  are  most  indefinite  in  comparison 
with  those  in  the  vascular  apparatus."  He  mentions 
a  case  that  died  at  the  beginning  of  the  second  stage, 
in  which  the  vascular  lesions  were  intense  and  the 
implication  of  both  the  vascular  and  support  neuroglia 
was  profound,  but  the  investigation  of  the  neurones 
gave  practically  negative  results  with  modern  methods. 

W.  Ford  Robertson  ^  summarizes  what  appears  to 
him  to  be  the  most  probable  hypothesis  regarding  the 
pathogenesis  of  general  paresis  as  follows:  "The 
disease  depends  upon  the  occurrence  of  a  general 
toxic   condition,   the   exact  nature   of    which   is   still 

'  For  an  exhaustive  discussion  of  both  sides  of  the  question  with 
references,  see  Pathology  of  Mental  Diseases  by  W.  Ford  Robertson,  p. 
344  et  seq. 


Fig.  I. — Normal  capillaries  of  human  cerebral  cortex.  Bevan  Lewis's  fresh  method. 
X  500.     (Clouston.) 

Fig.  2.— Capillaries  of  cerebral  cortex  from  a  case  of  advanced  general  paresis,  showing 
marked  thickening  and  granularity,  and  increase  in  number  of  nuclei. 
Bevan  Lewis's  fresh  method.     X  300.     (Clouston.) 

Fig.  3.— Greatlv  hypertrophied  neuroglia  cells,  surrounding  an  arteriole  in  the  deepest 
laver  of  the  cortex,  in  a  case  of  advanced  general  paresis.  Aniline  black 
fresh  method.  (■;  500.)  The  arteriole  shows  periarteritis.  The  nerve-cells 
have  for  the  most  part  disappeared.  Those  that  remain  show  advanced 
pigmentary  degeneration.    (Ford  Robertson.) 

Fig.  4.— Normal  nerve-cell,  showing  the  chromophile  elements  of  the  protoplasm  and 
the  cone  of  origin  of  the  axis-cylinder  process.     (Ford  Robertson.) 

Fig.  5.— Three  cortical  nerve-cells  from  a  case  of  advanced  general  paresis,  showing 
slow  degenerative  changes  of  primary  type;  a.  cell  with  large  pigmentary 
accumulation  in  the  protoplasm  and  pallor  and  slight  disintegration  of  the 
chromophile  bodies;  />,  advanced  chromatolysis  ;  r,  advanced  chromato- 
lysis,  loss  of  processes  and  commencing  disintegration  of  the  nucleus. 
(Ford  Robertson.) 


PUie  XIIL 


*      *9f 


I. 


If' 


**// 


■i^ 


r 


PATHOLOGY.  263 

obscure,  but  which  is  certainly  in  many  cases  the 
result  of  antecedent  syphilitic  infection.  The  first 
important  effect  produced  by  the  toxins  is  a  prolifer- 
ative and  degenerative  change  in  the  walls  of  the 
vessels  of  the  central  nervous  system,  including  those 
of  the  capillaries  of  the  cerebral  cortex.  This  alter- 
ation in  the  capillary  walls  interferes  in  various  ways 
with  the  nutritive  exchanges  between  the  blood  and 
the  cerebral  tissues.  Consequently  the  adjacent  cor- 
tical neurones  undergo  primary  degeneration  and  the 
neuroglia  also  tends  to  suffer  certain  morbid  alter- 
ations. At  the  same  time  these  tissues  are  to  some 
extent  affected  directly  by  the  toxic  agents  circulating 
with  the  blood."  He  places  special  stress  upon  the 
influence  of  the  changes  found  in  the  capillaries  and 
is  a  strong  believer  that  these  vascular  lesions  are  due 
to  a  toxic  condition.  This  view  first  advocated  by 
Angiolella  is  held  by  many,  even  the  majority  of 
those  who  do  not  believe  that  the  blood-vessels  are 
first  attacked,  believe  that  "general  paresis  is  due 
to  toxins,  the  result  of  auto-intoxication  from  previ- 
ous infection  of  the  system  by  syphilis  or  other 
poisons." 

Among  the  advocates,  which  are  many,  of  the  view 
that  the  neurone  suffers  primarily  may  be  prominently 
mentioned  Nissl,  Tuczek  and  F.  W.  Mott,  the'latter  has 
recently  in  a  number  of  papers  supported  this  theory.^ 
He  believes  it  to  be  "  like  tabes  a  primary  degeneration 
of  the  neurone,  with  meningo-encephalitis  that  is 
secondary."  This  is  due,  he  thinks,  to  a  premature 
failure  of  the  specific  vital  energy  of  the  neurone.  In 
this  view  of  the  cause,  he  differs  from  some  of  the 
other  advocates  of  this   theory,  who  believe  that  the 

1  Archives  of  Neurology,  1889,  Vol.  i,  p.  7  ;  ibid.,  p.  166.  Brit.  Med. 
Jour.,  Nov.  25,  1899;  /(&/(/.,  June  23,  1900.  Trans.  London  Path.  Soc, 
1900,  II,  p.  339. 


264  PATHOLOGY  AND  PATHOLOGICAL  ANATOMY. 

degeneration  of  the  neurone  is  due  to  the  intiuenee  of 
a  toxic  principle  of  some  sort.  With  such  eminent 
advocates  of  both  views  it  does  not  seem  advisable  in 
a  work  such  as  this  to  advance  any  dogmatic  opinion. 
The  references  given  will  enable  any  who  desire  to 
study  the  matter  for  himself.  It  seems  safe  to  say, 
however,  that  whether  the  primary  seat  of  the  lesion 
is  in  the  blood-vessel  or  in  the  neurone,  that  the 
cause  is  a  toxic  principle,  the  nature  of  which  is  not 
understood,  but  is  probably  in  most  cases,  at  least, 
the  outcome  of  a  previous  syphilitic  infection.  In 
this  connection  should  be  mentioned  the  recently  ex- 
pressed views  of  W.  Ford  Robertson  and  Lewis  C. 
Bruce  ^  that  general  paresis  is  due  to  a  toxemia  of 
gastro-intestinal  origin,  due  to  overgrowth  of  the  bac- 
teria that  normall}'  dwell  in  the  alimentary  tract,  and 
that  S3'philis  acts  as  a  predisposing  cause  by  altering 
the  normal  immunity.  This,  while  not  yet  confirmed 
by  others,  is  novel  and  interesting. 

The  Viscera. — In  respect  to  the  condition  of  the 
body  and  viscera  of  patients  dying  of  general  paresis 
it  has  been  found  by  comparison  that  the  patholog- 
ical records  of  the  Government  Hospital  for  the  In- 
sane, Washington,  D.  C,  and  the  State  Hospital, 
Norristown,  Pa.,  institutions  where  the  writer  for- 
merly served,  conform  very  closely  to  the  published 
results  of  Mickle,  derived  from  a  large  series  of  post- 
mortem examinations.  Hence,  as  confirmatory  of 
ample  experience,  an  abstract  of  these  results  may  be 
given: 

Body-nutrition. — In  about  one  half  of  the  cases  the 
nutrition  of  the  body  was  fair  or  good ;  in  nearly  fifty 
per  cent,  there  was  some   degree  of  emaciation,  of 

1  British  Medical  Journal,  June  29,  1901. 


LIVER.  265 

whom  one  half  at  least  may  be  said  to  have  shown 
extreme  emaciation.  Only  a  relatively  insignificant 
number,  less  than  three  per  cent.,  were  very  fat. 

Heart. — Pericardial  fluid  was  somewhat  increased 
in  one  third  of  the  cases.  Blood:  usually,  the  right 
chambers  of  the  heart  were  full,  the  left  ventricle 
nearly  empty.  The  cardiac  clots  were  softish,  oc- 
casionally firm,  rarely  was  the  blood  entirely  fluid. 
The  heart-muscle  was  more  or  less  softened  and  un- 
duly flabby,  or  friable  in  about  two  thirds  of  the  cases. 
One  or  both  of  the  valves  of  the  left  side  of  the  heart 
were  altered  in  at  least  two  fifths;  increased  thick- 
ness, opacity,  atheromatous  and  calcareous  changes 
were  by  far  the  most  frequent;  but  vegetations, 
cohesions,  valvular  obstruction  or  incompetency 
were  occasionally  seen.  In  two  per  cent,  there  was 
marked  dilatation  of  the  heart  and  in  eight  per  cent, 
marked  hypertrophy.  In  about  half  of  the  cases,  one 
or  both  of  the  coronary  arteries,  especially  the  left, 
were  found  to  be  more  or  less  atheromatous. 

Lungs. — Old  pleuritic  adhesions  or  pleuritic  thick- 
enings were  noted  in  two  thirds;  hypostatic  conges- 
tion, or  marked  congestion  and  edema  of  bases,  in 
more  than  two  thirds ;  and  some  serous  fluid  in  pleura 
in  nearly  half  of  the  cases.  In  one  third  of  the  autop- 
sies there  was  more  or  less  pulmonary  tuberculosis, 
occasionally  there  was  ordinary  caseous  (catarrhal) 
phthisis.  In  one  third,  marked  hypostatic  pneumonia 
and  in  one  fourth  of  the  cases  there  was  a  form  of 
lobular  pneumonia;  both,  occasionally,  were  found 
with  or  passing  into  slight  local  gangrene. 

Liver. — In  about  half  of  the  cases  there  was  marked 
passive  congestion  of  the  hepatic  veins;  and  in  one 
sixth  of  these  the  appearance  was  distinctly  "  nut- 


266  PATHOLOGY  AND  PATHOLOGICAL  ANATOMY. 

meggy."  The  hepatic  substance  was  unduly  friable, 
or  flabby  in  eleven  per  cent.,  merely  too  firm  in  six 
per  cent,  and  in  eleven  per  cent,  it  was  slightly  cir- 
rhotic. In  a  small  per  cent,  of  the  cases  the  liver- 
capsule  was  thickened  and  in  about  the  same  number 
there  were  old  perihepatitic  adhesions  to  neighboring 
parts. 

Spleen.  —  In  nearl}^  one  half,  the  spleen  was  de- 
cidedly too  firm;  in  a  small  per  cent,  unduly  soft. 
In  a  few  cases  its  capsule  was  extremcl}-  pigmented 
and  in  an  equal  number  the  spleen  was  unusually 
notched. 

Kidneys.  —  In  nearly  one  half  of  the  cases  some 
marked  morbific  change  in  the  kidneys  was  found. 
In  eighteen  per  cent,  the  kidneys  were  noted  as  being 
markedly  cirrhotic,  or  atrophied  and  granular;  in 
thirty-four  per  cent,  the  capsules  were  adherent;  and 
in  twelve  per  cent,  there  was  discovered  the  ordinary 
cystic  change.  The  kidne}  s  were  found  congested 
in  eighteen  per  cent.  In  two  to  four  per  cent,  the 
following  conditions  were  recorded:  Marked  lobula- 
tion; extremely  thickened  capsules;  fatty  kidney; 
induration  (independent  of  "  granular  "  change) ; 
locally  cicatrized  surface;  old  perirenal  adhesions; 
horseshoe  kidney,  and  renal  calculus. 


CHAPTER  XVIII. 

TREATMENT. 

I.  Prophylactic  Treatment.  {a)  Hereditary  Pre- 
disposition.— Prophylactic  treatment,  without  doubt, 
would  be  the  most  important  division  of  treatment,  if 
it  could  be  made  effective,  because  it  reaches  not  one 
life  alone  but  many.  The  first  consideration,  then,  in 
the  treatment  of  general  paresis,  is  the  eradication  of 
any  tendency  towards  hereditary  predisposition. 

While  general  paresis  is  not  so  largely  a  hereditary 
disease  as  some  of  the  other  forms  of  insanit}^,  yet 
even  here  the  fruits  of  a  weakened  nervous  constitu- 
tion tell  on  the  next  generation  with  no  abatement  of 
force.  We  find  that  in  a  large  number  of  paretics  the 
brain  is  defective  from  birth,  so  that  while  the  parents 
for  the  most  part  have  not  been  subjects  of  the  disease, 
paresis  in  the  oflfspring  has  resulted  from  a  vitiated 
state  of  the  brain,  entailed  by  other  neuropathic  con- 
ditions in  the  parents. 

Profiting  by  the  general  knowledge  in  the  preven- 
tion of  hereditary  diseases,  many  of  the  ills  of  life 
could  be  escaped,  if  medical  men  in  general  practice, 
with  courage  equal  to  their  convictions,  would  assert 
the  dangers  of  the  neuropathic  predisposition.  The 
physician  is,  and  must  be,  the  conservator  of  the  pub- 
lic health  and,  looking  to  the  welfare  of  posterity,  he 
should  use  his  influence  to  the  utmost  to  root  out  any 
preventable  tendency  to  weakness  and  disease  in  the 
race.  Clearly  it  should  be  his  duty  to  impress 
strongly  on  the  minds  of  his  patients  the  necessity  of 
the  avoidance  of  the  marriage  of  neuropathic  people. 

267 


268  TREATMENT. 

With  less  forethought  than  the  breeders  of  cattle,  we 
never  raise  our  voice  against  the  "  sowing  of  tares," 
in  the  pernicious  habit  of  indiscriminate  marriage  of 
the  "  unfit." 

Never  has  there  been  a  time  when  the  teachings  of 
the  medical  profession  have  claimed  more  attention 
than  to-day.  This  condition  is  laro-elv  due  to  an 
intelligent  public,  who  by  their  wide  general  reading 
and  consequent  application  of  scientific  truths,  are 
ready  to  heed  the  warnings  thus  pointed  out,  which  a 
generation  or  two  ago  would  have  fallen  on  deaf  ears. 
This  state  of  affairs  is  the  good  soil  on  which  the 
family  physician  should  not  neglect  to  scatter  his  seed 
of  good  advice  most  faithfulh'.  It  is  only  by  the 
development  of  a  healthy  public  sentiment  that  such 
good  can  be  accomplished,  for  laws  will  never  be 
enforced  unless  in  harmony  with  the  ideas  of  the 
communit}'.  Hence  legislative  action  should  follow, 
not  precede,  public  sentiment.  Later,  cautious  legis- 
lation can  cr3'stallize  the  sentiments  developed  in  a 
community  by  the  concerted  action  of  thousands  of 
physicians. 

(/?)  Individual  Predisposition. — A  more  active 
field  promising  more  immediate  results,  is  the  removal 
of  individual  predisposition. 

The  children  already  endangered  by  a  vicious 
heredity  should  be  given,  so  far  as  possible,  a  balance 
against  the  onset  of  disease.  The  earlier  this  is 
established  the  better;  herein  lies  one  of  the  oppor- 
tunities of  the  physician.  He  may  do  much  towards 
securing  for  the  individual  a  healthy  body,  if  he 
insists  that  self-control,  freedom  from  excitement  and 
over-tire  be  maintained;  that  a  healthful  moral  and 
intellectual  training  shall  be  given;  and  that  well- 
balanced  mental  powers  be  developed  with  broad- 
minded    judicious    habits    of    considering    religious, 


TREATMENT  OF  THE  ESTABLISHED  DISEASE.    269 

social,  and  intellectual  subjects.  The  energies  should 
be  directed  into  proper  channels  and  later  the  lesson 
be  taught  that  strain  of  worry  or  excess  of  any  kind 
is  poison  to  mind  and  body.  In  many  cases  should 
be  emphasized  the  dangers  from  the  over-strain  and 
over-living  of  the  twentieth  century  civilization, 
resulting  not  only  in  paresis,  but  in  the  many  forms 
of  neuropathic  heritage.  Thus  the  physician  should 
enlighten  and  warn;  and  b}'  every  prophylactic  means 
in  his  power  strive  to  ward  off  the  encroachment  of 
this  dire  scourge  of  modern  times. 

(c)  The  Tlireatejied  Attack. — A  still  broader  field 
of  prophylactic  treatment  is  the  actual  prevention  of 
an  impending  attack  of  general  paresis  by  removing 
the  patient  from  the  circumstances  or  environment 
under  which  premonitory  symptoms  have  been  ob- 
served and  reo;ulatinor  the  life  so  that  such  an  attack 
is  lessened  or  removed.  This  means  the  regulating  of 
every  movement  of  the  patient,  the  removal  of  all 
strain  or  excess,  the  use  of  regular  bodily  exercise, 
early  hours  for  retiring,  massage  and  bathing,  the 
gentle  use  of  the  intellectual  and  moral  faculties,  the 
avoidance  of  wines,  tobacco  and  coition.  It  is  abso- 
lutely essential  to  cut  the  patient  otf  from  severe  work 
and  anxiety  and  yet  judgment  must  be  used.  It  may 
require  a  determined  effort  on  the  part  of  the  physi- 
cian bu^  he  should  not  be  disheartened  or  rebufted  by 
the  patient's  environment  but  gently  and  firmly  force 
him  into  other  life.  It  is  not  necessar}'  to  do  this 
hurriedly  or  ill-advisedly  but  by  degrees  the  patient 
can  be  made  to  do  things  that  misfht  be  deemed 
absurd  or  impossible  if  forced  upon  him  m  an  mjudi- 
cious  manner. 

2.  Treatment  of  the  Established  Disease. — The  very 
early  stage  of  the  disease  is  the  one  that  presents  op- 
24 


270  TREATMENT. 

portunities  most  favorable  for  treatment,  and  the  only 
period  in  which  hope  of  permanent  relief  can  be  as 
yet  entertained.  The  care  of  general  paresis,  nat- 
urally, divides  itself  into  the  hygienic  management  of 
the  case,  as  separate  from  the  strictly  medical  treat- 
ment. 

As  the  former  life  of  the  paretic  is,  in  a  large  de- 
gree, responsible  for  his  breakdown,  the  causes  that 
have  brought  on  him  his  misfortune  must  be  closely 
studied  and  the  axe  laid  at  the  root  of  the  tree.  By 
attention  to  healthful  means  the  general  tone  of  the 
system  can  be  built  up,  and  by  a  judicious  regulation 
of  the  habits  and  life  of  the  patient  much  can  be  done, 
at  this  time,  to  check  the  impending  tendencies  of  the 
malady.  The  stress  of  the  environment,  or  of  busi- 
ness strain,  if  ever  relieved  to  the  benefit  of  the  patient, 
can  best  be  accomplished  at  this  period,  if  the  friends 
are  tactful  in  their  intiucnce.  In  some  cases  the 
patient  may  even  be  informed  of  the  gravity  of  the 
results,  if  he  persists  in  his  course  of  worr}'  or  excess, 
and  if  he  be  at  all  in  a  condition  to  be  swayed  by 
wise  motives,  he  may  be  brought  to  a  realizing  sense 
of  the  folly  of  his  ways. 

If  at  this  stage,  freedom  from  mental  anxiety,  change 
of  scene,  and  a  personal  interest  in  other  less  absorb- 
ing surroundings,  can  be  secured,  together  with 
hygienic  conditions  of  living,  there  is  fair  prospect 
that  healthy  cerebral  activity  may  be  restored  and 
sufficient  force  acquired  to  thwart  the  advance  of  the 
morbific  processes.  One  author  says:  "More  or  less 
complete  arrest  of  the  disease  may  be  favored  by  the 
recognition  of  its  early  stage,  and  by  treatment  which 
practically  amounts  to  putting  the  brain  in  a  splint, 
as  it  were."  Voisin  in  France  and  Meynert,  among 
the  Germans,  have  expressed  a  confident  belief  that 
paresis  is  susceptible  of  cure  in  its  earl}-  stage.     Mey- 


TREATMENT  OF  THE  ESTABLISHED  DISEASE.    27 1 

nert  based  his  belief  on  the  theory  that  preceding  and 
causing  the  diffuse  cortical  encephalitis,  there  is  a 
functional  vaso-motor  disorder,  which  he  considered 
curable. 

The  means  here  to  be  pursued  are  much  the  same 
as  those  which  are  employed  as  prophylactic  meas- 
ures. It  implies  a  careful  oversight  and  control  of 
the  details  of  the  patient's  living;  work,  both  mental 
and  physical,  reduced;  the  removal  of  all  stress  and 
strain;  abstemious  habits  of  living,  such  as  the  avoid- 
ance of  wines,  tobacco  and  coition;  the  use  of  mild 
bodily  exercise,  early  hours  and  watchful  care  of 
sleep;  a  suitable  diet  and  very  careful  attention  to 
the  state  of  the  bowels;  the  application  of  massage 
and  a  systematic  course  of  hydrotherapy,  combined 
with  the  partial  "  rest  cure."  In  certain  cases  elec- 
tricity in  some  of  its  forms  will  be  found  of  advantage. 
The  physician  must  not  yield  to  any  discouraging  ex- 
igencies in  the  patient's  surroundings,  but  gently  and 
firml}',  by  the  influences  at  his  command,  direct  the 
life  of  the  patient  into  more  wholesome  channels. 

If  there  is  impaired  health  the  bodil}'  functions 
should  receive  attention,  the  general  condition  built 
up,  with  tonics  if  necessary,  and  such  plan  of  treat- 
ment instituted  for  this  end,  as  best  meets  the  views 
of  the  individual  practitioner.  But  rest,  fresh  air, 
wholesome  food,  moderate  exercise  and  regular  hours 
will  be  found  to  be,  as  ever,  the  greatest  restorers  of 
energy. 

Even  in  suspected  cases,  where  the  diagnosis  has 
not  been  fully  made  out,  it  is  well  to  advise  rest;  and 
in  most  cases  removal  from  the  daily  occupation  and 
surroundings.  At  this  time  the  question  of  travel  will 
force  itself  on  the  attention  of  the  physician.  The 
word  "  travel "  is  attractive  to  the  mind  of  the  over- 
worked  practitioner  and   patient;  in  truth,  it  has  a 


272  TREATMENT. 

sweet  sound  to  most  cars.  But  it  is  now  generally 
recognized  that  travelling  of  any  kind  is  conducive  to 
more  harm  than  good  to  a  paretic  patient,  attended 
with  its  hurr}',  anno3'ance  and  excitement.  There 
can  be  no  doubt  that  a  change  of  environment  will 
always  be  of  benefit;  but  the  special  form  of  the 
change  must  be  left  to  the  discretion  of  the  advisors, 
in  each  individual  case,  which  must  be  decided  in 
accordance  with  the  circumstances.  Danger  from 
suicide,  or  assault,  may  have  to  be  guarded  against, 
and  the  very  prevalent  risk  of  dissipation  of  property 
should  be  ever  kept  in  view.  If  the  removal  from 
home,  in  the  early  stage,  should  involve  the  loss  01 
income,  or  be  a  serious  interference  in  business,  so 
that  the  anxiet}'  resulting  would  be  of  greater  injury 
to  the  patient,  then  a  lightening  of  labor  alone  may  be 
insisted  on,  together  with  the  adjustment  of  the  home 
life. 

The  subject  of  food  needs  further  elucidation.  In 
the  first  stage,  when  there  is  much  excitement,  the 
diet  should  be  light  and  easily  digestible,  and  abso- 
lutely prohibitory  of  alcohol  in  any  form.  It  will  be 
difficult  to  insure  temperate  eating  and  drinking,  for 
the  appetite,  always  large,  is  frequently  so  voracious 
that  nothing  short  of  over-repletion  will  satisfy  the 
patient's  desire.  In  the  later  stages  the  nourishment 
should  be  more  generous.  Milk  and  eggs  may  be 
placed  at  the  head  of  the  list.  These  articles  of  diet 
can  be  prepared  in  many  ways,  so  as  to  prove  tempt- 
ing dainties  to  the  sick.  Vegetables,  celery,  aspara- 
gus tops,  and  fruit  should  be  freel}'  allowed.  Meats 
on  the  other  hand  should  be  restricted.  Owing  to 
paresis  of  the  muscles  of  deglutition  much  care  must 
be  exercised  that  the  patient  does  not  choke,  or  that 
food  is  not  introduced  into  the  trachea.  By  easy 
gradations  the  food  administered  must  pass  from  solid 


GENERAL    MEDICAL    TREATMENT.  273 

to  minced  and  from  that  to  liquid  form,  in  the  last 
months  of  his  life.  Alcohol,  which  at  first  is  with- 
held, may  be  given  with  benefit  in  the  third,  or  last, 
stage. 

As  stated  under  etiology,  there  is  at  present  a  strong 
trend  in  the  belief  among  psychiatrists  towards  the 
theory  that  general  paresis  is  an  affection  due  to 
chronic  toxemia.  There  are  indications  also  that  the 
poison  is  of  bacterial  origin  through  the  digestive 
system.  These  observers  uniformly  teach,  whether 
they  believe  the  primary  process  to  be  nervous  or  vas- 
cular, that  the  natural  immunity  of  the  gastro-intes- 
tinal  tract  is  modified  by  the  breaking  down  of  those 
forces  which  control  normal  metabolism.  The  light 
that  recent  phj'siological  chemistry  and  bacteriology 
has  brought  to  the  solution  of  this  problem  may  soon 
mark  the  pathway  to  remedial  measures,  such  as 
specific  serums  or  other  antitoxins,  that  will  neutralize 
the  influence  of  these  poisons  which  gain  access  to  the 
circulation.  If  this  hypothesis  should  be  confirmed 
it  is  not  improbable  that  this  malady,  thus  far  fatal, 
may  be  transferred  in  a  few  years  to  the  list  of  curable 
diseases. 

General  Medical  Treatment. — As  yet  there  is  no  spe- 
cific drug  or  class  of  drugs  which  can  be  regarded  as 
at  all  remedial  in  character.  This  should  not  be  a 
cause  for  discouragement,  however,  for  much  may  be 
done  to  alleviate  the  various  conditions  and  to  retard 
the  progress  of  the  disease.  It  is  necessary  to  bear 
in  mind  always  that  the  most  unaccountable  remis- 
sions may  appear  from  time  to  time,  even  in  the  final 
stages,  so  that  the  physician's  efforts  should  not  be 
relaxed,  or  his  prognosis,  as  to  the  immediate  results, 
be  too  gloomy.  The  plan  of  treatment  suggested  in 
the  prodromic  period  should  be  continued  and  it  is 


2  74  TREATMENT. 

well  to  remember  that  in  an  affection  which  promises 
so  little  from  the  use  of  drugs  the  hygienic  and 
mental  management  of  the  case,  together  with  effi- 
cient nursing,  hold  the  chief  place  in  the  treatment. 

In  making  a  review  of  the  therapeutic  history  of 
general  paresis,  one  becomes  clearly  convinced  of 
what  a  mightv  struggle  there  has  been  waged  against 
this  formidable  disease.  It  would  seem  that  there  is 
scarcelv  anv  drug  or  remedial  measure,  at  all  applic- 
able, that  has  not  been  brought  to  bear  against  it. 
Counter-irritation,  derivation,  revulsion  by  blisters, 
suppurants,  cauteries,  or  setons  to  the  neck,  spine 
or  scalp;  venesection^  and  leeching;  and  repeated 
paintings  with  iodin  have  been  faithfully  applied  but 
should  be  rejected  as  too  severe  and  of  doubtful  utility. 
Veratrum  viride,  tartar  emetic  and  diuretics;  nitrate 
of  silver,  zinc,  physostigma,  papaverine  and  apomor- 
phia,  have  had  their  adherents  in  the  past,  but  are 
seldom  resorted  to  at  the  present  day.  We  mention 
them  in  order  to  call  attention  to  the  fact  that,  now 
and  then,  some  good  has  resulted  from  the  use  of  them. 

Tonics. — In  manv  cases,  in  the  early  stages  that 
are  free  from  excitement,  there  are  indications  for 
the  use  of  tonics,  and  most  cases  call  for  this  plan  some 
time  during  the  course  of  the  disease,  especially  if 
the  patient  be  enfeebled,  emaciated,  exhausted  or 
phthisical.  They  should  not  be  given  indiscrimi- 
nately, much  skill  can  be  displayed  in  the  choice  of 
them,  which  must  be  left  in  great  measure  to  the 
judgment  of  the  attending  physician.  Among  the 
most  prominent  may  be  mentioned  the  preparations 
of   iron,  the  vegetable  tonics,   cod-liver  oil,  the   hy- 

*  A  man  who  had  decided  to  commit  suicide  by  letting  his  blood,  felt  so 
much  better  after  considerable  blood  had  escaped,  that  he  had  the  wound 
bound  up  again.  Also  a  gentleman  greatly  depressed  in  mind  who  was 
being  bled  :  as  the  blood  tlowed,  he  gradually  changed  and  tinally  began  to 
joke,  etc.     (Abstract,  Sankey,  op.  cit.,  p.  311.) 


GENERAL    MEDICAL    TREATMENT.  275 

pophosphites,  quinine,  strychnia,  arsenic  and  phos- 
phorus. The  number  of  elegant  pharmaceutical  for- 
mulas containing  these  in  various  combinations  in  the 
market  is  legion. 

Sedatives, — There  is  a  long  list  of  drugs  of  this 
class,  which  would  carry  us  into  too  great  prolixity 
to  discuss  separately.  The  selection  or  combination 
used  is  susceptible  of  a  widely  varying  discriminat- 
ing choice.  The  chief  ones  are:  Opium,  morphine, 
bromides,  chloral,  cannabis  indica,  veratrine,  hyos- 
cyamin,  hyoscine,  duboisin,  sulphonal,  trional,  hypnal, 
tetranal,  paraldehyde,  chloralamide,  antipyrin  and 
chloretone. 

Ergot,,  Ergotin. — Ergot  or  ergotin  has  enjoyed 
some  reputation,  when  administered  continually  for 
a  long  time,  in  moderate  doses,  in  relieving  the  cere- 
bral congestion,  underlying  excitement,  and  in  ward- 
ing off  congestive  seizures,  but  its  value  has  not 
been  uniformly  apparent  and  it  has  fallen  into  general 
disuse. 

Digitalis,^  Digitalin. — Digitalis  has  been  em- 
plo3^ed  by  French  and  English  physicians,  to  combat 
maniacal  excitement,  and  the  tendency  to  cerebral 
congestion,  with  fairly  good  results,  but  there  are 
drawbacks  and  dangers  to  its  use  that  seem  to  check 
enthusiasm. 

AntisypJiilitic  Remedies. — The  observations  of 
Collins,^  under  antisyphilitic  treatment  in  tabes, 
equally  apply  to  the  advisability  of  antisyphilitic 
treatment  in  paresis.  When  syphilis  is  the  causative 
factor  neuro-alienists  are  not  agreed  as  to  the  impor- 
tance of  specific  treatment.  Some,  following  Charcot, 
steadfastly  hold  that  such  treatment  is  useless,  no 
matter  how  indifterently  the  patient  may  have  been 
treated  during  the  active  period  of  the  S3'philitic  poi- 

1  Treatment  of  Nervous  Diseases,  p.  233. 


276  TREATMENT. 

son,  providing  that  the  symptom-complex  of  paresis 
did  not  develop  within  a  short  time  after  the  syphilitic 
infection,  from  two  to  four  years,  when  the  lesion  ma}' 
be  properly  considered  a  true  S3'philitic  and  not  a 
parasyphilitic  one. 

On  the  contrary,  others,  following  Erb,  recommend 
an  active  course  of  antisyphilitic  medication  in'cvery 
case  of  paresis  with  a  history  of  S3'philis,  or  even  upon 
the  suspicion  of  a  taint,  or  where  this  method  will 
speedily  clear  up  any  confusion  with  cerebral  svphilis. 
Berkley  ^  inaugurates,  at  once,  inunctions  of  blue  oint- 
ment, or  oleate  of  mercury,  or  the  hypodermic  admin- 
istration of  the  bichloride,  or  the  sozoiodolate  of  mer- 
cury in  salt  solution.  While  his  preference  is  for  the 
mercurial  salts,  he  uses,  also,  the  iodide  of  potassium 
in  doses  gradually  increasing  to  sixty  grains  or  up- 
wards, thrice  daily.  In  these  cases.  Osier  ~  pre- 
scribes large  doses  of  the  iodide  of  potassium.  Collins 
believes  that  the  best  results  can  be  obtained  by  the 
use  of  mercury  by  inunction;  if  this  method  cannot 
be  carried  out  then  its  use  h3'podermatically.  Mer- 
cur}',  as  specific  means,  he  believes  should  be  given 
in  no  half-hearted  way.  He  is  accustomed  to  use 
from  thirt}'  to  fort}'  grains  of  blue  ointment  rubbed  in 
daily,  each  application  lasting  from  twenty  to  thirty 
minutes  and  the  course  continued  from  five  to  six 
weeks.  He  cautions  watchfulness  over  the  condition 
of  the  patient's  alimentary  tract,  skin  and  body  weight. 
Too  much  care  cannot  be  taken  to  keep  him  clean, 
much  in  the  open  air  and  well  fed.  Great  importance 
is  attached  to  the  maintenance  of  the  body  weight;  if 
this  cannot  be  done  the  mercury  should  be  stopped 
at  once.  After  the  mercury  treatment  has  been  sus- 
pended, the  patient  should  receive  a  vigorous  tonic 
plan  of  treatment  for  several  months. 

1  Mental  Diseases,  p.  195. 

^Practice  of  Medicine,  3d  ed..  p.  964. 


GENERAL    MEDICAL    TREATMENT.  277 

The  author  agrees  with  Collins  that  nothino-  is  to 
be  expected  from  the  administration  of  mercury,  be 
it  by  the  mouth,  inunctions,  or  h3'podermatically,  in 
cases  of  genuine  paresis  in  which  no  syphilitic  mani- 
festations are  present  but  that  harm  even  may  arise 
from  such  a  course.  On  the  other  hand,  iodide  of 
potassium,  given  in  small  doses  and  for  a  long  time, 
especially  in  conjunction  with  measures  that  improve 
the  nutrition  and  husband  the  energy,  is  one  of  the 
most  valuable  drugs  to  delay  the  decay  of  the  pri- 
mary neuron. 

Electricity. — Either  static,  constant  or  induced,  in 
the  hand  of  some  practitioners,  who  are  skilled  in  its 
application,  is  highly  extolled,  especially  in  the  pro- 
dromal stage.  Combined  as  it  is  apt  to  be  with  mas- 
sage and  other  devises  employed  in  asthenic  nervous 
conditions  it  has  often  been  attended  with  good  re- 
sults. The  head  and  spine  are  the  regions  to  be 
treated. 

Hydrothei'apy. — Douches,  the  warm  bath  with  cold 
to  the  head,  wet  pack  and  other  forms  of  application 
of  water  cure  have  been  very  useful  in  the  hands  of 
many  in  the  treatment  of  the  initial  period;  and,  also, 
in  the  later  stag-es  this  form  of  treatment  has  at  times 
brought  about  marked  amelioration  of  the  symptoms. 
In  the  Government  HospitaP  at  Washington,  as  an  in- 
stance, this  plan  of  treatment  was  instituted  a  few 
years  ago  and  the  physicians  speak  most  enthusias- 
tically of  the  results.  For  details  in  the  application  of 
electricity,  hydrotherapy,  massage  and  rest  treatment 
the  student  is  referred  to  the  well-known  works  on 
nervous  diseases. 

Tre-phining. — Although  of  occasional  value,  surgi- 
cal measures  have  proved  unsatistactory.  Trephining 
has  been  practiced  chiefly,  over  the  parietal  region, 

'  Forty-first  Annual  Report,  p.  160. 
30 


278  TREATMENT. 

both  in  this  country  and  abroad.  The  operation  was 
originally  proposed  on  the  supposition  that  in  paresis 
there  was  present  an  increased  intracranial  pressure. 

Treatment  of  Special  Symptoms. — In  the  treatment  of 
the  special  symptoms  the  same  general  principles 
must  be  adopted  that  are  found  to  be  efficacious  in 
the  relief  of  the  same  symptoms,  in  other  forms  of 
mental  disease. 

]\fe?ital  Excitetneui.  —  Sankey  recommends  the 
combination  of  digitalis  and  opium,  as  advised  by  M. 
Dumesnil.  He  gives  it  in  the  proportion  of  one 
drachm  of  the  tincture  of  opium  (Br.)  to  ten  minims 
of  the  tincture  of  digitalis,  every  four  hours,  until  the 
patient  becomes  more  tranquil  or  sleeps.  Peterson 
resorts  to  hyoscin,  hyoscyamin,  or  duboisin  (gr.  yj^r 
to  gr.  yV))  hypodermically,  in  periods  of  maniacal 
excitement.  Dercum  speaks  highly  of  antipyrine 
(gr.  X  to  gr.  xx),  every  four  hours.  The  bromides, 
chloral,  sulphonal  and  trional,  by  others,  are  given 
separately  or  combined,  and  paraldeh3de  for  the  same 
purpose,  to  induce  quiet  and  sleep.  The  use  of  the 
hot  bath,  with  cold  to  the  head,  followed  by  isola- 
tion, are  good  tranquilizing  agents,  as  well  as  the  wet 
pack. 

Insomnia.  —  In  the  earlier  stages  of  paresis,  the 
patient  often  suffers  acutely  from  sleeplessness,  which 
serves  to  aggravate  the  other  nervous  symptoms. 
The  remedies  suggested  in  the  period  of  mental  ex- 
citement may  all  be  of  service  in  insomnia.  Paralde- 
hyde, in  doses  of  twenty  to  thirty  minims,  may  be 
given  at  bed  time,  or  double  this  amount  suspended 
in  thin  mucilage,  administered  by  the  bowel.  As 
Stearns  has  said,  there  is  less  objection  by  paretics 
to  this  drug,  on  account  of  taste,  than  by  other  classes 
of  invalids.     Some  alienists  keep  to  the  use  of  chloral 


TREATMENT    OF    SPECIAL    SYMPTOMS.  279 

In  preference  to  the  newer  remedies.  A  combination 
of  equal  parts  of  trional  and  sulphonal  answers  well 
as  a  hypnotic  in  many  instances.  The  rapidly  induced 
effects  of  the  former  are  supplemented  by  the  less 
transient  action  of  the  latter  drug.  These  two  last- 
named  drugs  are  not  very  poisonous  in  single  over- 
dose, but  there  is  a  variety  of  chronic  poisoning  by 
them  that  may  be  even  more  serious,  brought  about 
by  too  long  duration  of  their  use.  The  symptoms 
are  an  obstinate  constipation,  diminished  quantity  of 
urine  and  hematoporphyrinuria.  If  treatment  be 
prolonged,  one  should  be  on  his  guard  for  the  toxic 
symptoms.  Constipation  of  marked  obstinacy  with 
scanty  dark  red  urine,  should  at  once  excite  suspicion. 

Chloretone  has  not  passed  the  stage  of  experimenta- 
tion, but  already  its  unfavorable  record  as  a  depres- 
sant of  the  heart  raises  a  danger  signal  to  its  pro- 
miscuous use. 

Epile-ptiform  Seizures. — Many  agencies  have  been 
sugsested  for  the  relief  of  these  attacks.  Setons  and 
vesicants  to  the  nape  of  the  neck,  painting  the  neck 
with  iodine,  and  trephining  have  accomplished  but 
little.  The  continuous  use  of  the  bromides  for  long 
periods  of  time  is,  perhaps,  the  best  treatment  to  ward 
off  threatened  attacks,  giving  attention,  in  the  mean- 
time, to  the  general  condition  of  the  patient.  In  status 
epilepticus,  rectal  injections  of  chloral  in  starch 
water  are  recommended.  The  seizures  may  be  so 
marked  as  to  require  the  inhalation  of  chloroform. 
The  bowels  and  bladder  should  be  evacuated,  the 
lower  bowel  by  enemata.  A  drop  of  croton  oil  on 
the  tongue,  if  other  purgatives  cannot  be  given,  may 
relieve  the  cerebral  congestion  by  purgation. 

Apoplectiform  Seizures. — In  this  condition  the 
requirements  are,  the  elevation  of  the  head,  the  use 
of  free    purgation,  the    application    of    cold    to    the 


28o  TREATMENT. 

head,  with  or  without  a  prolonged  warm  bath.  The 
alkaline  bromides  and  ergot  are  recommended  in  full 
doses.  In  suitable  cases,  when  the  cerebral  congestion 
is  marked,  leeching,  blood-letting  by  venesection  or 
cup,  calomel,  digitalis,  camphor  enemata  have  all  been 
used.  Hot  mustard  foot  baths  seem  frequently  to 
arrest  an  attack. 

Bed-sores. — In  the  last  stages  of  paresis  much  care 
must  be  taken  to  prevent  the  forming  of  bed-sores. 
Perfect  cleanliness  should  be  enforced;  the  use  of  a 
water  bed,  with  frequent  changes  of  position,  and 
with  buffers  of  some  soft  antiseptic  material  over  the 
bony  protuberances,  is  indicated.  The  skin  may  be 
hardened  by  white  of  egg  and  spirits,  or  by  a  strong 
solution  of  tannin,  or  a  strong  solution  of  sulphate  of 
zinc.  If  sores  form,  despite  every  precaution,  they 
should  be  carefully  treated  and  watched.  Many  of 
these  sores  are  really  trophic  in  character  and  not  due 
to  pressure  at  all.  This  is  shown  by  the  fact  that 
they  appear  at  points  where  no  pressure  has  been 
exerted. 

Hughes  recommends  a  novel  plan  of  treatment. 
He  orders  the  sore  washed  with  warm  water  and 
castile  soap,  and  then  thoroughly  rinsed.  A  liquid 
preparation  of  beef  bovinine  is  poured  over  the  sur- 
face of  the  ulcer  and  the  surface  is  saturated  by  using 
pledgets  of  lint.  The  ulcer  is  carefully  covered,  as 
in  a  surgical  dressing.  Granulations  appear  gradually 
after  this  treatment,  followed  by  an  epithelial  cover- 
ing. This  treatment  is  effective,  for  the  tissue  thus 
formed  is  not  less  resistant  than  the  neighboring  skin. 

Terminal  Symptoms. — Life  in  the  open  air  is  ad- 
visable, as  long  as  it  can  be  continued;  as  soon  as  the 
patient  is  not  able  to  walk  alone  he  should  be  given 
assistance;  when  this  assistance  no  longer  avails,  a 
reclining  chair  should  be  used,  and  thence  by  stages, 


TREATMENT    OF    SPECIAL    SYMPTOMS.  201 

he  must  go  to  the  constant  use  of  an  air  or  water  bed. 

At  this  period  an  abundant  and  nourishing  diet 
should  be  used,  but  it  must  be  administered  with 
care;  the  paretic  is  apt  to  bolt  his  food  and  hence  is 
frequently  in  danger  of  choking.  There  is  danger, 
too,  of  the  inhalation  of  food  and  of  resulting  lobular 
pneumonia.  In  cases  of  dysphagia  it  may  be  neces- 
sary to  use  the  nasal  tube  in  giving  food;  in  these, 
and  in  very  demented  patients,  it  is  sometimes  im- 
perative, for  brief  periods,  to  administer  peptonized 
food  by  the  rectum. 

Perfect  hygiene  is  of  the  utmostjmportance.  Reg- 
ular bathing  must  be  continued  and  a  constant 
vigilance  for  bed-sores  be  maintained.  At  this  stage 
when  the  sphincters  are  paralyzed,  or  at  best  react 
sluggishly,  cleanliness  is  difficult  to  secure  but  is 
absolutely  necessary.  Excreta  should  be  removed 
promptly  and  every  precaution  taken  to  keep  the  skin 
free  from  irritation.  The  bowels  must  be  kept  open 
and  often  comparative  regularity  of  action  can  be 
secured  by  using,  at  stated  times,  a  simple  enema. 
Gentle  massage  also  may  be  used  to  secure  regularity 
of  the  bowels. 

In  cases  of  diarrhea,  often  troublesome  in  the  last 
stages  of  paresis,  the  matter  of  cleanliness  becomes  a 
great  tax,  but  it  must  be  maintained  with  most  as- 
siduous care,  and  the  diarrhea  must  be  given  the 
usual  treatment. 

Catheterization  should  be  avoided,  as  long  as  it  is 
possible  to  produce  urination  by  other  means.  The 
patient  must  be  encouraged  to  evacuate  his  bladder 
by  his  own  efforts,  and  to  complete  the  evacuation, 
gentle^  manual  pressure  may  be  used;  unless  this  is 
done  the  decomposition  of  the  residual  urine  quickly 
sets  up  cystitis. 

^  Be  sure  the  pressure  is  gentle,  for  too  great  force  may  result  in  rupture 
of  the  bladder. 


282  TREATMENT. 

By  such  constant  and  faithful  care,  the  life  of  the 
patient  may  continue  for  months,  in  a  weak  and  bed- 
ridden, but  still  comparatively  painless  condition. 


INDEX. 


A  BSCESS,  66,  150,  233,  23s 
^     Acute  mania  with  delusions,  17S 
Agapoff,  256 
Age  of  occurrence,  204 
Amenorrhea,  33 
Amnesia,  27-29,  30,  35,  110 
Analgesia  of  ulnar  nerve,  146 
Anesthesia,  local,  33,  62 
Angiolella,  214,  263,  283 
Anglade,  193 

Anglo-Saxons,  paresis  in,  210 
Anxiety  as  a  cause,  221 
Antisjphilitic  remedies,  275 
Aphasia,  117,  118 
Aphonia,  119,  132,  146 
Apoplectiform    seizures,    treatment 
of,  279 
attacks,  34,  58,  129 
Apoplexy,  177 
Appetite,  voracious,  55 
Argyll-Robertson  pupil,  93,  125,  139, 

1^8 
Arson,  act  of,  iii 
Arthropathy  of  knee  joints,  151 
Articulation,  impaired,  33,  45,  56,  65, 

117 
Atrophy,  optic,  26,  96,  139,  140,  141, 

195 
prog,  muscular,  150 
Auto-intoxication,  214,  263,  273 

DAILLARGER,  20,  75,  76 

^     Baker,  J.,  11 1 

Bacterial  infection,  214,  263,  273 

Ball,  21 

Ballet,  32,  259 

Bannister,  193,  204 

Bayle,  19,  41 

Bed-sores,  65,  72,  100,  150,  157,  241 

treatment  of,  280 
Bell,  Luther,  21 
Berkley,  35,  62,  80,  iii, 112,  188,  193, 

248,  261 
Bettencourt-Rodrigues,  124 


Bianchi,  124 
Bigamy,  40 
Bladder,  rupture,  281 

trouble  in  paresis,  169 
Blandford,  35,  77,  82,   88,    181,    233, 

237-  239,  240 
Blood  changes  in,  151,  164 

sweating,  147 

-vessels  of  brain,  pathology  of, 
252 
Body  nutrition,  264 
Bones,  158,  160 
Bonnet,  193 
Brain,   pathology  of,  246 

macroscopic,  246 

microscopic,  251 

in  acute  cases,  247 

in  chronic  cases,  248 
Briscoe,  239 
Bronchitis,  86 
Brush,  238 
Bucknill,  50,  57 
Bucknill  &  Tuke,  50,  215,  217,    232, 

233 
Burr,  C.  B.,  158,  160,  236 

pALMEIL,  19,  22,  75 

^     Campbell,  Alfred,  260 

Clark,    34,    38,    43,    72,   78, 
85,  92,  96,  115,    132,    135, 
198 
Catheterization,  281 
Carbuncles,  233 
Causes,  17,  1S7   (see  Etiology) 
Cephalalgia,  175 
Cerebellum,  pathology  of,  249 
Cerebral  seizures,  58,64,  127,129,171 
Chapin,  187 

Character,  change  of,  28,  31,  34 
Charcot,  93,  105,  192,  275 
Children  of  paretics,  189 
Christian,  128,  218 
Chorea'and  paresis,  228 
Chronic  alcoholic  insanity,  173 


283 


284 


INDEX. 


Circular  form,  82 

typical  cases  of  (Blandford), 
82 
{ Campbell-Clark ) , 

84 
(Magnan),  S3 
(Savage),  83 
Classes,  higher  and  lower,  211 
Classification  of  varieties,  73 
Climacteric,  influence  of,  106 
Clouston,  24,  47,  53,  61,  67,   85,   86, 
90,  95,  97,  124,  134,  136,  140,   146, 
147,  158,   161,   189,   218,   224,   237, 
248 
Collins,  275 

Commencement,  mode  of,  22 
Congestion  of  optic  discs,  142 
Congestive  attacks,  58,  67 
Conjugal  general  paresis,  107 
Contractures,    26,   65,    69,    72,    100, 

102,  107,  139,  197,  214 
Cortex,  pathology  of,  248 
Cranium,  pathology  of,  246 
Curability,  probable  future,  273 
Cystitis,  chronic,  167 

nAWSON,  142,  148 
^     Deafness,  143,  146,  217 
Decortication,  247,  250 
Defects  of  speech,  33,  45,  57,65,  117 
Definition  of  paresis,  22 
Deglutition,  impaired,  66,  67,  90 
Delaye,  17,  19 

Delusions  of  grandeur,  25,  38,  41,  47, 
49,  50,  59,  62,  68,  70,  71,  207, 
227" 

of  persecution,  83,  142 
Dementia,  simple  progressive,  94 
Dercum.  60,  194,  213,  215,  237,  259 
Developmental  paresis,  93,  97-106 
De  Boismont,  30 
Diet,  272 
Deiters'  cells,  253 
Differential  diagnosis,  172 

acute  mania  with  delusions,  178 

apoplexy,  177 

chronic  alcoholic  insanity,  173 

disseminated  sclerosis,  180 

epilepsy,  177 

lead  poison,  180 

paralysis  agitans,  181 

paralytic  insanity,  175 

senile  insanity,  179 

syphilitic  insanity,  174 


Diagnosis,  tabes  dorsalis,  iSo 

typical  cases  of  diagnosis(  Bland- 
ford),  181 
(F'olsom),  182,  185 
(Tomlinson),  183 
Digestive  disorders,  33 
Discovery,  date  of,  18 
Disseminated  sclerosis,  180 
Double  for  in,  82 
Doutrcbcnte,  18S 
Down,  91 

Dvial  theory  of  paresis,  17,  20 
Dunn,  E.  L.,  102 
Dura,  pathology  of,  246 
Duration,  236 

typical  cases  (Brush  and  Sink- 
ler),238 
(Blandford),  239 
(Briscoe  I,  239 
(Fisher,  E.D.), 237 
(Journal      of       Mental 

Science),  239 
(Lapointe),  238 
Dysmenorrhea,  33 

PARLY  life,  paresis  in,  93,  97-106 
^''     Edema  of  lungs,  241 
Electricity,  277 

Emaciation,  64,  66,  70,  72,  loo,  265 
Embolism,  242 
Epilepsy,  177,  21S 
Epileptiform  attacks,  34,  40,  58,  62, 
70,  72,83,96,95,  133,  196, 
200 
treatment  of,  279 
Erb,  276 

Erysipelas,  233,  242 
Esquirol,  19 
Etiology,  1S7 

age,  204 

typical  cases   (Savage),  206 
(Tomlinson ),  306 
epilepsy,  218 

typical     cases     of     (Chris- 
tian I,  218 
(Sankey),  219 
(Workman),  218 
excesses,  212 
heredity,  187 

typical  cases  of  (Charcot),  191 
(Clouston    &    Sav- 
age), 189 
(Grannelli),  193 
(Hotchkis),  190 


INDEX. 


285 


Etiology,  heredity,  typical  cases  of 
(Mott),  191 
(Muller),  192 
(Revue      de     Psy- 

chologie),   190 
(Wilson,    G.    R.), 
189,  190 
injury  to  the  head,  214 

theory  of  Dercum,  215 
typical   cases    of    (Bucknill 
&Tuke),  215,  217 
(Clouston),  217 
(Mickle),  216 
(Neff),  216 
(Rayner),  215 
(Sankey),  216 
intellectual  overwork,  221 

typical   cases  of  (Sankey), 
222,  223 
(Savage),  221 
physical  overwork  and  strain,  220 
race   and  social   influences,  209 
table  by  Spitzka,  210 

typical     case      (Work- 
man), 212 
sex,  201 

ratio  of  liability,  201 
table  by  Regis,  201 
typical    cases   (Bannister), 
204 
(Marr),  204 
(Middlemass),  202 
(Sankey),  203 
syphilis,  193 

statistics,  by  Bannister,  193 
by  Berkley,  193 
by  Graf,  193 
by  Houghberg,  193 
by  Kraepelin,  193 
by  Lewis,  193 
hy  Mendel,  193 
by  Peterson,  193 
typical  cases   of   (Campbell 
Clark),  19S 
(Folsom),  198 
(Norman),  195,  199 
(Savage),  195,  197 
(Von  Rad),  197 
temperament,  200 

typical  case  (Savage),  102 
toxic  agents,  214 

theory  of  Angiolella,  21^ 
typical  cases  (Stearns),  213 
(Wiglesworth),  214 


Exaltation,    30,  31,    35,    42,   50,  52, 

53>  62 
Exhaustion,  64 

Exposure  to  cold  causing  paresis,  220 
Excesses,  212 
Eye  symptoms,  137 

'CACIA.L  expression,  46,  57,  60,  96, 
-•■       116,  200 
Farrar,  Reginald,  17 
Fatigue,  early,  34 
Finnegan, 142 

First  stage  (second  period),  41 
mental  symptoms  of,  41 
hypochondriacal,  43 
maniacal  excitement,  43 
melancholia,  43 
physical  symptoms  of,  44 
defects  of  speech,  45 
facial  expression,  46 
pupillary  anomalies,  45 
tremor,  45,  46 
tjpical   cases    of    (Bucknill 
and  Tuke),  So 
(Clouston),  47,  53 
(Fox),  48 

( Hammond) ,  50,  54 
(Sankey),  49 
Fisher,  E.  D.,  37,  96,  23S 
Flechsig,  259 
Food, 272,  2S1 
Folsom,  34,  36,  37,  40,  73,  79,   108, 

109,  1S2,  183,  1S5,  188,  19S 
Fournier,  194 
Foville,  162 
Fox,  48,  155 

Fracture  of  bones,   159,  160 
Froelich,  161 

pAIT,  40,  46,  48,  58,  61,  65,  66,  Si, 
^     103,  120,  127,  143 
Galloping  form,  80 
Gangrene  of  lip,  155 
Gastric  crisis,  33,  85 
Geil,  259 

General    paresis  following  ordinary 
insanity,  79)  224 
following  paranoia,  79 
j  Georget,  19 
Germans,  paresis  in,  210 
Giannone,  146 
Grannelli,  193 

Gray  matter,  pathology  of,  249 
Griesinger,  34 


286 


INDEX. 


Giiislain,  214 

Gun,  tiring  of,  exciting  cause,  217 

TJALLUCINATIONS,  72,  85,  90, 

•^1     114.  131,  217 

Hair,  150 

Hammond,  29,  40,  50,  54,  63 

Handwriting,  1 19 

Haslam,  18 

Headache,  33,  34,  128 

Hebrews,  paresis  in,  210 

Heart,  pathology  of,  265 

Hematoma  auris,  161,  195 

Hemiplegia,  38,  72,  95,  133,  209 

Heredity,  82,  106,   187,  267 

Higher  and  lower  classes,  2H 

Hirschl,  205 

History  of  paresis,  iS 

Hoch,  Aug.,  104 

Hoche,  259 

Hoestermann,  79 

Homicidal  impulse,  43,  61,  198,  20S 

Hotchkis,  190 

Houghberg,  194 

Hughes,  D.  E.,  79,  280 

Hurd,  H.  M.,  33,  233 

Hydrotherapy,  271,  277 

Hypochondria,  43,  61 

Hypothetical      case     in     prodromal 

stage  (Sankey),  24 
Hysteroid  attacks,  129 

INJURY  to  the  head,  214 
^      "  Insane  ear,"  161 
Incontinence  of  urine,  169 
Insomnia,  32,  47,  90,  145 

treatment  of,  278 
Intellectual  overwork,  221 
Irish,  paresis  in,  210 
Irritability,  a  symptom,  30,  34,  37-39, 
43.61 

TELLIFFE,  8i 
J     Joffray,  93,  190,  259 
Joy,  excessive,  a  cause,  222 
Juvenile  paresis,  93,  97-106 
in  sisters,  97,  102 

I/"  AT  ATONIC  symptoms,  128,  217 

'^     Kidneys,  pathology  of,  266 

Kiernan, 214 

Klippel  &  Servaux,  170 

Knapp,  141 

Knee-jerk,  relative  frequency,  125 


Kraepelin,  193 
Kraftt-Ebing,  22,  iSS 

T  ANGDON,  166 

j  *-^     Lapointe,  238 

I  Lateral  columns,  implication  of,  89 

j  Lead  poison,  180 

"  Leather-coated  jack,"  159 

Lemoine,  1S8 
I  Lewin,  193 

Lewis,  Bevan,  27,  29,  30,  31,  74,  88, 
I  122,  127,  133,  135,  137,"  164,  251, 
I      253,  255,  258,  261 

Liver,  pathology  of,  2615 

Lloyd,J.  H.,  153 

Locomotor  ataxia,  90,  91 

Lungs,  pathology  of,  265 

Lunier,  20,  76,  188 

MABILLE,  162 
Macleod,  165 

Macpherson,  64,  146,  151 

Magnan,  84,  190 

Malaria,  paresis  mistaken  for,  109 

Maniacal  excitement,  43,  48,  278 

Manner  of  development,  18 

Marr,  204 
I  Marie,  228 
I  Marinesco,  256 

Massage,  271 

Masturbation,  114 

Medico-legal  aspect,  30,  44 
;  Medulla,  pathology  of,  249 

Meeson,  170 

Melancholic  form,  85 
I  Medical  treatment,  273 

Mendel,  193,  218 

Menses,  alteration  in,  106 

Mental  excitement,  treatment  of,  278 
shock,  221 
symptoms    of    general    paresis, 

41 
symptoms    of    prodromal  stage, 
27 
of  first  stage,  41 
second  stage,  55 
of  third  stage,  64 
Meynert,  78,  270 

Mickle,   24,  77,   114,    125,    146,    165, 
193,  205,  211,    213,    215,   216,   221, 
224,  248,  249,  251 
Middlemass,  106,  109,  203,  225 
Mills,  89,  259 
Migraine,  146 


INDEX. 


287 


Mode  of  commencement,  22 
Moral  perversion,  28,  40,  71,  no 
Morselli,  22 
Mortimer,  231 
Mott,  191,  259,  263 
Muller,  192 

Muscular  atrophy,  150 
incoordination,  65 

MACHE,  18S 

^^     Nageotte,  259 

Nails,  150 

Neff,  216 

Negro,  209,  210,  212 

Nerve  cell,  pathology  of,  255 

Nerves,    peripheral,    pathology    of, 

260 
Neuritis,  optic,  33,  140 

peripheral,  69 
Neuroglia,  pathology  of,  253 
Newcombe,  133 

Nightmare,  early  symptom,  145 
Nissl,  263 
Norman,  98,  197,  200 

OPISTHOTONOS,  129 
^     Optic  neuritis,  33,  140 
Organic  dementia,  175 
Osier,  276 

pAINS,  32,  61,  72,  145 
-*■       Paralysis  agitans,  iSi 
Paralytic  insanity,  175 
Parchappe,  20,  75 
Paresis  in  brothers,  201 

in  daughter,  tabes  in  mother,  192 
in  mother  and  child,  191,  192 
ratio  to  other  insanities,  201 ,211 
vs.  syph.  brain  dis.,  174,  193 
Paresis  without  insanity,  21 
Paresthesia,  33 
Parsons,  168 

Particular  symptomatology,  no 
apoplectiform  attacks,  129 

typical   cases  of   (Campbell 
Clark),  132 
(Tomlinson),  129 
bladder,  169 
bones,  158 

typical  cases  (Burr,  C.  B.), 
159,  160 
(Froelich),  i6o 
classification  by  Lewis,  127 
epileptiform  attacks.  133 


Particular  symptomatology,  epilepti- 
form    attacks,    typical     cases    of 
(Campbell    Clark) 

135 
(Clouston),       134, 

135. 
(Lewis),  134 
( Spitzka),  134 
eye  symptoms,  137,  typical  cases 
(Clouston),  140 
(Dawson    &    Ram- 

baut),  142 
(Finegan),  142 
(Knapp),    140 
(Savage),  142,  143 
(Stearns),  143 
(Wiglesworth),  141 
facial  expression,  116 
gait,  120 

hallucinations,  114 
handwriting,  119 
headache,  146 
hematoma  auris,  161 
moral  perversion,  no 

typical  cases  of  (Baker,  J.), 
Ill 
(Berkley),  111,  112 
(Simon),  113 
(Spitzka),  112 
(Stearns),  in 
vertigo,  122 
pains,  145 
pulse,      168 

reflex  action  and  reflexes,  123 
crossed  reflexes,  126 
pupillary  reflexes,  125 
typical  case  (Clouston),  124 
sensory  disturbances,  146 

typical  cases  of  (American 
Journal     of     In- 
sanity), 147 
(Dawson  &    Ram- 

baut),  148 

(Spitzka),  147 

(Stearns),  147 

(Sullivan),  148 

sexual  instinct,  113 

typical  cases   of  (Stearns), 

"3 

sleep,  145 
speech,  117 

aphasia,  118 

typical  cases  of  (Rosen- 
thal), 118 


288 


INDEX. 


Particular  symptomatology,  speech, 
typical  cases  of  (Savage),  119 
syncopal  attacks,   127 

typical   cases    of  (Naecke), 
128 
(Christian),  12S 
(Stearns),  12S 
temperature,  164 

typical  case  (Parsons),  167 
tremor,  123 
trophic  changes,  149 

typical  cases   of   (Abstract, 
Arch,     de     Neu- 
rol.), 155 
(Burr,  C.  B.),  ISS 
(Fox),  153 
(Lloyd,  J.  H.),  151 
unilateral  twitching,  136 

typical    cases    of    (Lewis), 

137 
(Turner),  136 
urine,  169 
Pathogenesis    of   paresis,    194,   214, 

263-  273 
Pathology,  246-266 

body  nutrition,  264 
heart,  265 
kidneys,  266 
liver,  265 
lungs,  265 
spleen,  266 
viscera,  264 

macroscopic,  of  brain,  246 
of  cerebellum,  249 
of  cortex,  248 
of  cranium,  246 
of  dura,  246 
of  gray  matter,  249 
of  medulla,  249 
of  pons,  249 
of  spinal  cord,  250 
of  white  matter,  249 
microscopic,  of  brain,  251-257 
of  blood-vessels,  252 
of  nerve-cell.  255 
of  neuroglia,  253 
Perfect,  18 
Peripheral    nerves,    pathology    of, 

260 
Personality,  changed,  131 
Peterson,  166,  193 
"  Petrified  face,"  116 
Phelps,  107,  227 
Phlegmon,  242 


Physical  overwork  and  strain,  220 
symptoms  of  general  paresis  of 
prodromal  stage,  32 
of  first  stage,  44 
of  second  stage,  56 
of  third  stage,  64 
Pick,  69 
Pickett,  125 
Pierret,  188 
Pleurothotonos,  129 
Pneumonic  hypostasis,  129 
Pons,  pathology  of,  249 
Posterior  sclerosis,  89,  90 
Posture,  changes  in,  57 
Precocious  paresis,  93,  97-106 
Prodromal  stage,  27 

mental  symptoms,  27 
insomnia,  32 
moral  perversion,  40 
physical  symptoms,  32 
amenorrhea,  33 
anesthesia,  ^^ 
depression,  38 
digestive  disorders,  33 
dysmenorrhea,  33 
grandiose  delusions,  38 
irritability,  38,  39 
motor  troubles,  33, 37, 39 
paresthesia,  33 
hypothetical     case      in 
prodromal  stage ( San- 
key),  24 
typical  case  in  (Blandford), 

(Campbell  Clark), 

38'  40 
(Fisher),  37 
(Folsom),  37,  40 
(  Hammond),  40 
(Savage),  38 
(Sinkler),39 
(Spitzka),39 
Prognosis,  239 

supposed    recoveries   (Savage), 
240,  241 
(Spitzka),  241 
Prophvlactic  treatment,  267 
Pulse,"  168 

Pupillary  anomalies,  14,  37,  45,  48, 
57,  Si,  125,  138 

DACE  and  social  influences,  209 
•'^*-     Rambaut,  142,  148 
Raymond,  100,  259 


INDEX. 


289 


Rajner,  215,  231 

Recovery,  supposed, 240,  241 

Reflex  action  and  reflexes,  123 

iridoplegia,  138 
Reflex-excit.  excess.,  case  of,  124 
Reflexes,  abolition  of,  65 
crossed,  126 
superficial,  124 
Regis,  21,  188,  201,  211 
Reguin,  120 

Respiration  in  sleep,  145 
Retention  of  urine,  169 
Rest  cure,  271 
Remissions,   22S 

following  abscesses,  235 
typical  cases  of  (Burr),  235 

(Savage),  233 
following     carbuncles,      typical 

cases  of  (Stearns),  233 
slough  (White),  233,  234 
typical      cases      of       remission 
(Blanford),  233 
(Bucknill     and   Tuke), 

231,  232 
(Mortimer),  231 
(Rayner),  231 
(Spitzka),  232 
(Stearns),  231 
(Whitcombe),  230,  232 
Ribs,  fracture,  15S 
Robertson,  W.  Ford,  255,  256,  262 

CACRAL  decubitus,  65,  72,  150,  2S0 

^     Sankey,  24,   49,  69,  72,  75,   100, 

116,    159,    201,  204,  216,  222, 

223,  244 

Savage,    18,    21,   26,   27,  34,  38,  70, 

81,  83,  87,  90,   93,    97,    107,    119, 

143,   168,   195,   197,  20I,  206,  213, 

220,   222,  ?26,   234,  240,  241,  242, 

245     - 
"  Scavenger  cells,"  255 
Schules,  241 

Sclerosis  of  spinal  cord,  251 
Second  stage  (third  period),  55 

illustrative   case    in    (Berk- 
ley),  62 
(Clouston),  II 
(Dercum),  59 
(Hammond),  62 
mental  symptoms,  55 
physical  symptoms,  56 
apoplectic  attacks,  58 
congestive  attacks,  58 

19 


Second  stage,    physical    symptoms, 
epileptic  attacks,  58 
impaired     articulation, 

56 
posture,  changes  of,  57 
pupils,  changes  in,  57 
skin,  changes  in,  57 
tremulousness,  58 
Sedatives,  275 
Salmi,  170 
Senile  insanity,  179 
paresis,  109 ,  206 
Sensory  disturbances,  146 
Septic  infection,  241 
Sex,  201 
Sexual  ability  lost,  114,  135 

instinct,  113 
Shafer,  256 
Shaw,  76,  146 
Simon,  113,  240 
Sinkler,  39,  238 
Skin,  changes  in,  33,  46,  57 
Slave,  formerly,  develops  p.,  212 
Sleep,  32,  145,  278 
Sodomy,  190 
Spasm,    facial,    on     protrusion     of 

tongue,  137 
Special  symptoms,  treatment  of,  278 
Speech,  33,45,  56,65,  117 
Spinal  cord,  pathology  of,  250,  258 
sclerosis  of,  251 
general  paresis,  88 
symptoms  in  women,  106 
Spitzka,  28,  30,  39,  44,  73,  87,   113, 
114,  115,   134,    147,    168,    172,  210, 
232,  239,  241 
Spleen,  pathology  of,  266 
Stages  of  paresis,  23 

(Mickle),  24 
(Clouston),  24 
Stearns,  32,  66,  86,  91,  95,  iii,   112, 
113, 122, 128, 144, 148, 213, 231, 233 
Sterility,  189 
Strabismus,  142 
Suicide,  212,  242,  272,  274 
Sullivan,  W.  C,  149 
Sunstroke,  exciting  cause,  215 
Suppuration,  240,  241 
Symptomatology,   no 
Symptoms,   terminal,    treatment  of, 

280 
Syncopal  attacks,  127 
Syncope,  128 
Synonyms  of  paresis,  22 


290 


INDEX. 


Syphilis,  193 
Syphilitic  insanitj,  174 

origin,  72,  92,  96,  148,  166 
Sjphilization,  reciprocal,  107 

qpABES  dorsalis,  180,  259 
•*■      in  child  of  paretic,  191 
relation  to  paresis,  259 
Tache  cerebrale,  137 
Tabetic  form,  91 
Teeth,  56,  150 
Temperament,  200 
Temperature,  133,  164 
Terminal    symptoms,    treatment  of, 

280 
Termination,        typical        cases 
(Sankey),  243 

(Savage),  244 

(Christian),  225 

(Clouston),  224,  226 

(Middlemass),  225 

^Phelps),  227 

(Savage),  226 

(Worcester),  227 

( Vallon  and  Marie),  228 
Testamentary  capacity,  44 
Tetanoid  seizures,  129 
Theories  of  paresis,  21 
Thieving,  a  symptom,  30 
Third  stage  (fourth  period),  64 
mental  symptoms  of,  64 
phjsical  symptoms  of,  64 

bed-sores,  65 

change  in  speech,  65 

exhaustion,  64 

emaciation,  64 

muscular  incoordination,  65 

reflexes,  abolition  of,  65 
typical      cases      of      (Campbell 
Clark),  72 

(Clouston),  66 

(Pick),  68 

(Stearns),  66 

(Sankey).  68,  70 

(Savage),  69 
Tomlinson,  132,  184,  209 
Tonics,  274 

Toxemia,  chronic,  214,  263,  273 
Toxic  agents,  214 
Traumatism  of  brain,  214 
Travel  as  a  remedy,  271 
Treatment,  prophylactic,  267 

in     hereditary     predisposi- 
tion, 267 


Treatment,    prophylactic     in     indi- 
vidual predisposition,  268 

in  threatened  attack,  269 
of  established  disease,  269 

food,  272 

hydrotherapy,  271,  277 

massage,  271 

rest  cure,  271 

travel,  271 
medical,  273 

antisyphilitic  remedies,  275 

sedatives,  275 

tonics,  274 
of  special  symptoms,  278 
Tremor,  33,  45,  46,  56,  58,  65,  122 
Trephining,  277 
Trophic  changes,  65,  149 
Tuberculosis,  85,  241 
Tuczek,  257,  263 
Turner,  J.,  136 
Twins,  paresis  in,  1S9,  201 

UNILATERAL  twitching,  136 
Ulcerations,  150 
Ulcer  of  foot,  perforating,  66,  150 
Ulnar  nerve,  analgesia  of,  146 
Urine, incontinence,  retention  of,  169 
Urea,  170 

yALLON,  162,  22S 
*       Varieties  of  paresis,  73 

classifications  of  by    (Bail- 
larger),  75 
by  (Folsom),  73 
by  (Lewis,  B.),  74 
by  (Meynert),  78 
by  (Mickle),  77 
by  (Sankey),  75 
by  (Spitzka),  73 
by  ( Voison),  76 
by  (Shaw),  76 
dementia,    simple    progres- 
sive, 94 

typical     case     of, 
(Clouston),  94 
(Stearns),  95 
(Campbell 

Clark),  95 
(Fisher,     E. 

D.),96 
(Savage),  96 
double  form,  82 

typical  cases  of  (Bland- 
"  ford),  82 


INDEX. 


291 


Varieties,  double  form  typical  cases  of 
(Campbell  Clark),  84 
(Magnan),  83 
(Savage),  83 
galloping  form,  80 

typical    cases     of   (Jel- 
liffe),  81 
(Savage),  80,  81 
juvenile  form,  97 
typical  cases  of  (Norman), 
98 
(WiglesMTorth),  99 
(Sankey),   100 
(Raymond),    101 
(Dunn,  E.  L.),  102 
(Hoch,  Aug.),  104 
(Charcot),  105 
(Middlemass),   106 
melancholic  form,  85 

typical  cases  of  (Blan- 
ford),  87 
(Clouston),  86 
(Savage),  87 
(Spitzka),  87 
(Stearns),  86 
spinal  general,  paresis,  88 

classification    of,    B  e  v  an 

Lewis,  88 
typical  cases  of  (Campbell 
Clark),  91 
(Clouston),  90 


Varieties,    spinal,    typical   cases     or 
(Down),  91 
(Joffroy),  93 
(Savage),    89,    90, 

92 
(Stearns),  91 
Vaso-motor  disturbances,  33,  45,  85, 

137,  271 
Vertigo,  33,  122,  127,  132,  140 
Viscera,  pathology  of,  260 
Voison,  76,  164 
Von  Rad,  197 

WALLERIAN  law,  89,  217 
White,  233 
Whitcombe,  230,  232' 
White  matter,  pathology  of,  249 
Wiglesworth,  99,  100,  141,  214 
Willis,  18,  19 

Wilson,  G.  R.,  186,  189,  190 
Wolfenden,  170 
Woman,  paresis  in,.  106,  201,  206 

typical    case   of    (Savage), 
107 
(Folsom),  108,  109 
(Middlemass,  toS 
Worcester,  228 
Workman,  212,  219 

VACHER,  So 
"     Ziehlen,  239 


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MORRIS.  Text-Book  ot  Anatomy.  2d  Edition.  Revised  and 
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Thumb  Index  in  Each  Copy.  Cloth,  g6.oo  ;  Leather,  ^7.00 

"  The  ever-growing  popularity  of  the  book  with  teachers  and  students 

is  an  index  of  its  value." — Medical  Record,  New  York. 

BROOMELL.  Anatomy  and  Histology  of  the  Human  Mouth 
and  Teeth.     2d  Edition,  Enlarged.     330  Illustrations.  ^4  50 

CAMPBELL.  Dissection  Outlines.  Based  on  Morris' Anatomy. 
2d  Edition.  .50 

DEAVER.     Surgical  Anatomy.     A  Treatise  on  Anatomy   in  its 
Application  to  Medicine  and  Surgery.    With  400  very  Handsome  full- 
page  Illustrations  Engraved  from  Original  Drawings  made  by  special 
Artists  from  dissections  prepared  for  the  purpose.     Three  Volumes. 
Cloth,S2i.oo;  Half  Morocco  or  Sheep,  $24.00;  Half  Russia,  $27. 00 

GORDINIER.  Anatomy  of  the  Central  Nervous  System. 
With  271  Illustrations,  many  of  which  are  original.  Cloth,  $6.00 

HEATH.     Practical  Anatomy.     8th  Edition.     300  Illus.  ^4.25 

HOLDEN.  Anatomy.  A  Manual  of  Dissections.  Revised  by  A. 
Hewson,  M.D.,  Demonstrator  of  Anatomy,  Jefferson  Medical  College. 
Philadelphia.  320  handsome  Illustrations.  7th  Edition.  In  two 
compact  i2mo  Volumes.  850  Pages.  Large  New  Type.  Just  Ready. 
Vol.  I.  Scalp^Face — Orbit — Neck — Throat — Thorax — Upper  Ex- 
tremity. gi.50 
Vol,  II.  Abdomen — Perineum — Lower  Extremity — Brain — Eye — 
Ear — Mammary  Gland — Scrotum — Testes.                51.50 

HOLDEN.  Human  Osteology.  Comprising  a  Description  of  the 
Bones,  with  Colored  Delineations  of  the  Attachments  of  the  Muscles. 
The  General  and  Microscopical  Structure  of  Bone  and  its  Develop- 
ment.   With  Lithographic  Plates  and  numerous  lUus.   8th  Ed.     $5.25 

HOLDEN.     Landmarks.    Medical  and  Surgical.    4th  Ed.  .75 

HUGHES  AND  KEITH.  Dissections.  With  a  large  number  ot 
Colored  and  other  Illustrations.     In  three  Parts : 

I,  Upper  and  Lower  Extremity.  fust  Ready.     ^3.00 

II,  Abdomen — Thorax.  Just  Ready.    I3.00 

III,  Head — Xeck — Central  Nervous  System.        Just  Ready.     ^3.00 

MACALISTER.  Human  Anatomy.  Systematic  and  Topograph- 
ical.    816  Illustrations.  Cloth,  $5.00;  Leather,  $6.00 

McMURRICH.     Embryology.     270  Illustrations.  In  Press. 

MARSHALL.  Physiological  Diagrams.  Eleven  Life-Size 
Colored  Diagrams  (each  seven  feet  by  three  feet  seven  inches). 
Designed  for  Demonstration  before  the  Class. 

In  SLeets,  Unmounted,  $40. 00  ;  Backed  with  Muslin  and  Mounted 
on  Rollers,  ^60.00 ;  Ditto,  Spring  Rollers,  in  Handsome  Walnut  Wall 
Map  Case,  |ioo.oo;  Single  Plates — Sheets,  ^5.00 ;  Mounted,  $7.50 
Explanatory  Key,  .50.     Purchaser  must  pay  Jr  eight  charges. 

MINOT.     Embryology.     Illustrated.  Preparing. 

POTTER.  Compend  of  Anatomy,  Including  Visceral  Anatomy. 
6th  Ed.    16  Lith.  Plates  and  117  other  Illus.     .80 ;  Interleaved,  gi.oo 

WILSON.     Anatomy,     nth  Edition.    429  lUus.,  26  Plates.      P5.00 


SUBJECT  CATALOGUE. 


BRAIN  AND  INSANITY  (see  also 
Nervous  Diseases). 

BLACKBURN.  A  Manual  of  Autopsies.  Designed  for  the  Use 
of  Hospitals  for  the  Insane  and  other  Public  Institutions.  Ten  full- 
page  Plates  and  other  Illustrations.  fi-zs 

CHASE.     General  Paresis.     Illustrated.  Nearly  Ready. 

DERCUM.  Mental  Therapeutics,  Rest,  Suggestion.  See 
Cohen,  Physio. ogic  Ther.ipeutics,  p.ige  I2. 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Central 
Nervous  System.     With  full-page  and  other  Illustrations.      j^6.oo 

HORSLEY.  The  Brain  and  Spinal  Cord.  The  Structure  and 
Functions  of.     Numerous  Illustrations.  $2.50 

IRELAND.    The  Mental  Affections  of  Children.    2d  Ed.    $4.00 

LEWIS  (BEVAN).  Mental  Diseases.  A  Text-Book  Having 
Special  Reference  to  the  Pathological  Aspects  of  Insanity.  26  Litho- 
graphic Plates  and  other  Illustrations.     2d  Ed.  $7-°o 

MANN.    Manual  of  Psychological  Medicine,  ^3-oo 

PERSHING.  Diagnosis  of  Nervous  and  Mental  Disease. 
Illustrated  #'-25 

REGIS.  Mental  Medicine.  Authorized  Translation  by  H.  M. 
Bannister,  m.d.  ^2.00 

SCHOFIELD.     The  Force  of  Mind.  In  Press. 

SHUTTLEWORTH.     Mentally  Deficient  Children.  $1.50 

STEARNS.  Mental  Diseases.  With  a  Digest  of  L.^ws  Relating 
to  Care  of  Insane.     Illustrated.  Cloth,  J2. 75;  Sheep,  1^3.25 

TUKE.  Dictionary  of  Psychological  Medicine.  Giving  the 
Definition,  Etymology,  and  Symptoms  of  the  Terms  used  in  Medical 
Psychology,  with  the  Symptoms,  Pathology,  and  Treatment  of  the 
Recognized  Forms  of  Mental  Disorders.     Two  volumes.  Jio.oo 

WOOD,  H.  C,    Brain  and  Overwork.  .40 

CHEMISTRY  AND  TECHNOLOGY. 

special  Catalogue  of  Chemical  Books  sent  free  upon  application. 
ALLEN.     Commercial    Organic   Analysis.     A  Treatise  on  the 

Modes   of  Assaying  the  Various  Organic   Chemicals   and  Products 

Employed   in  the   Arts,  Manufactures,  Medicine,  etc.,  with  concise 

methods  for  the  Detection  of  Impurities,  Adulterations,  etc.     8vo. 

Vol.  I.  Alcohols,  Neutral  Alcoholic  Derivatives,  etc..  Ethers,  Veg- 
etable Acids,  Starch,  Sugars,  etc.     3d  Edition.  $4-5o 

Vol.  II,  Part  I.  Fixed  Oils  and  Fats,  Glycerol,  Explosives,  etc. 
3d  Edition.  j3-50 

Vol.  H,  Part  II.  Hydrocarbons,  Mineral  Oils,  Lubricants,  Benzenes, 
Naphthalenes  and  Derivatives,  Creosote,  Phenols, etc.  3d  Ed.  ^3.50 

Vol.  II,  Part  III.  Terpenes,  Essential  Oils,  Resins,  Camphors,  etc. 
3d  Edition.  Preparing. 

Vol.  Ill,  Part  I.  Tannins,  Dyes  and  Coloring  Matters.  3d  Edition. 
Enlarged  and  Rewritten.     Illustrated.  $4-5° 

Vol.  Ill,  Part  II.  The  Amines,  Hydrazines  and  Derivatives, 
Pyridine  Bases.  The  Antipyretics,  etc.  Vegetable  Alkaloids,  Tea, 
Coffee,  Cocoa,  etc.     8vo.     2d  Edition.  ?4-50 

Vol.  Ill,  Part  III.  Vegetable  Alkaloids,  Non-Basic  Vegetable  Bitter 
Principles.  Animal  Bases,  Animal  Acids,  Cyanogen  Compounds, 
etc.     2d  Edition,  8vo.  $4-50 

Vol.  IV.  The  Proteids  and  Albuminous  Principles.  2d  Ed.  $4.50 
BAILEY  AND  CADV.    Qualitative  Chemical  Analysis.    ^1.25 


MEDICAL  BOOKS. 


HARTLEY,    Medical    and    Pharmaceutical    Chemistry.     A 

Text-Book  for  Medical,  Dental,  and  Pharmaceutical  Students.   With 
Illustrations,  Glossary,  and  Complete  Index.     5th  Edition.         $3.00 

HARTLEY.  Clinical  Chemistry.  The  Examination  of  Feces, 
Saliva,  Gastric  Juice,  Milk,  and  Urine.  Ji.oo 

HLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experi- 
ments,    gth  Ed..  Revised.     281  Engravings.  Preparing. 

HUNGE.  Physiologic  and  Pathologic  Chemistry.  From  the 
Fourth  German  Enlarged  Edition.    Just  Ready.  $3.00 

CALDWELL.  Elements  of  Qualitative  and  Quantitative 
Chemical  Analysis.    3d  Edition,  Revised.  gi.oo 

CAMERON.     Oils  and  Varnishes.    With  Illustrations.  $2.25 

CAMERON.     Soap  and  Candles.    54  Illustrations.  ^2.00 

CLOWES  AND  COLEMAN.  Quantitative  Analysis.  5th 
Edition.     122  Illustrations.  $3.50 

COBLENTZ.     Volumetric  Analysis.    Illustrated.  gr.25 

CONGDON.  Laboratory  Instructions  in  Chemistry.  With 
Numerous  Tables  and  56  Illustrations.  jSi.oo 

GARDNER.  The  Brewer,  Distiller,  and  W^ine  Manufac- 
turer.    Illustrated.  Ji-So 

GRAY.  Physics.  Volume  I.  Dynamics  and  Properties  of  Matter. 
350  Illustrations.  ^4.5° 

GROVES  AND  THORP.    Chemical  Technology.    The  Appli- 
cation  of   Chemistry  to  the   Arts  and   Manufactures. 
Vol.  I.  Fuel  and  Its  Applications.     607  Illustrations  and  4  Plates. 

Cloth,  $5.00;  "%,  Mor.,  |6.so 
Vol.11.    Lighting.      Illustrated.  Cloth,  §4.00;  J^  Mor.,  $5.50 

Vol.  III.  Gas  Lighting.  Cloth,  ^3.50;  J^  Mor.,  ^4.50 

Vol.  I V.   Electric  Lighting.     Photometry.  In  Press. 

HEUSLER.     The  Terpenes.    Just  Ready.  J64.00 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Microscopi- 
cal, for  Laboratory  Use.     6th  Ed.     Illustrated  and  interleaved,  $1.00 

LEFFMANN.  Compend  of  Medical  Chemistry,  Inorganic 
and  Organic.     4th  Edition,  Revised.  .80;  Interleaved,  gi. 00 

LEFFMANN.      Analysis   of   Milk    and    Milk    Products.      2d 
Edition,  Enlarged.     Illustrated.  J1.25 

LEFFMANN.  W^ater  Analysis,  For  Sanitary  and  Technic  Pur- 
poses.    Illustrated.     4th  Edition.  ^1.25 

LEFFMANN.  Structural  Formulae,  Including  180  Structural 
and  Stereo-Chemical  Formulae.     i2mo.     Interleaved.  $1.00 

LEFFMANN  AND  BEAM.  Select  Methods  in  Food  Analy- 
sis.    Illustrated.  $2.50 

MUTER.  Practical  and  Analytical  Chemistry.  2d  American 
from  the  Eighth  English  Edition.  Revised  to  meet  the  requirements 
of  American  Students.     56  Illustrations.  ^1.25 

OETTEL.     Exercises  in  Electro-Chemistry.    Illustrated.        .75 

OETTEL.     Electro-Chemical  Experiments.     Illustrated.         .75 

RICHTER.  Inorganic  Chemistry.  5th  American  from  loth  Ger- 
man Edition,  Authorized  translation  by  Edgar  F.  Smith,  m.a., 
PH.D.     89  Illustrations  and  a  Colored  Plate.  $1.75 

RICHTER.  Organic  Chemistry.  3d  American  Edition.  Trans, 
from  the  8th  German  by  Edgar  F.  Smith.  Illustrated.  2  Volumes. 
Vol.    I.    Aliphatic  Series.     625  Pages.  S3. 00 

Vol.  II.    Carbocyclic  Series.     671  Pages.  fe.oo 


6  SUBJECT  CATALOGUE. 

ROCKWOOD.     Chemical  Analysis  for  Students  of  Medicine, 

Dentistry,  and  Pharmacy.     Illustrated.  Ji-so 

SMITH.     Electro-Chemical  Analysis.    2d  Ed.     28  lUus.       I1.25 

SMITH  AND  KELLER.  Experiments.  Arranged  for  Students 
in  General  Chemistry.     4th  Edition.     Illustrated  .60 

SUTTON.     Volumetric  Analysis,     A  Systematic  Handbook  for 

the  Quantitative  Estimation  of  Chemical  Substances  by   Measure, 

Applied  to  Liquids,  Solids,  and  Gases.      8th  Edition,  Revised.      112 

Illustrations.  _  $5.00 

SYMONDS.    Manual  of  Chemistry.    2d  Edition.  $2.00 

TRAUBE.     Physico-Chemical  Methods.    Translated  by  Hardin. 

97  Illustrations.  ^i-So 

THRESH.     Water  and  Water  Supplies.     3d  Edition.  J2.00 

ULZER  AND   FRAENKEL.     Chemical  Technical  Analysis. 

Translated  by  Fleck.     Illustrated.  $1-25 

WOODY.    Essentials    of    Chemistry    and    Urinalysis.      4th 

Edition.     Illustrated.  Ji-SO 

*»*  Special  Catalogue  0/  Books  on  Cheniistrv  free  upon  application. 

CHILDREN. 

CAUTLEY.     Feeding  of  Infants  and  Young  Children  by  Nat- 
ural and  Artificial  Methods.  $2.00 
HALE.    On  the  Management  of  Children.  .50 

HATFIELD.  Compend  of  Diseases  of  Children.  With  a 
Colored  Plate.     2d  Edition.  .80  :    Interleaved,  Ji.oo 

IRELAND.      The    Mental    Affections    of   Children.      Idiocy, 

Imbecility,  Insanity,  etc.     2d  Edition.  ^4.00 

POWER.  Surgical  Diseases  of  Children  and  their  Treat- 
ment by  Modern  Methods.     Illustrated.  ^z-So 

SHUTTLEWORTH,  Mentally  Deficient  Children.  Nevir 
Edition.  $i-5o 

STARR.  The  Digestive  Organs  in  Childhood.  The  Diseases  of 
the  Digestive  Organs  in  Infancy  and  Childhood.  3d  Edition,  Rewrit- 
ten and  Enlarged.     Illustrated.  J3.00 

STARR.  Hygiene  of  the  Nursery.  Including  the  General  Regi- 
men and  Feeding  of  Infants  and  Children,  and  the  Domestic  Manage- 
ment of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc.  6th 
Edition.     25  Illustrations.  ^i.oo 

SMITH.     Wasting  Diseases  of  Children.    6th  Edition.        ^2.00 

TAYLOR  AND  WELLS.  The  Diseases  of  Children.  2d  Edi- 
tion, Revised  and  Enlarged.     Illustrated.     8vo.  $4.5° 

DIAGNOSIS. 

BROWN.  Medical  Diagnosis.  A  Manual  of  Clinical  Methods. 
4th  Edition.     112  Illustrations.  Cloth,  $2.25 

DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  Exam- 
ination of  Blood.  6  Colored  Plates.  48  other  Illustrations.  Just 
Ready.  Cloth,  J5. 00;  Sheep,  $6  00 

EMERY.  Bacteriological  Diagnosis.  2  Colored  Plates  and  32 
other  Illustrations.    Just  Ready.  $i-50 

MEMMINGER.   Diagnosis  by  the  Urine.  zdEd.  34  IIlus.  fi.oo 


MEDICAL  BOOKS. 


PERSHING.     Diagnosis   of  Nervous  and   Mental   Diseases. 

Illustrated.  ^1.25 

STEELL.     Physical  Signs  of  Pulmonary  Disease.  $1.25 

TYSON.  Hand-Book  of  Physical  Diagnosis.  For  Students  and 
Physicians.  By  the  Professor  of  Clinical  Medicine  in  the  University 
of  Pennsylvania.  lUus.  4th  Ed.,  Improved  and  Enlarged.  With 
Two  Colored  and  55  other  Illustrations.  ?i-So 


DENTISTRY. 

special  Catalogue  of  Dental  Books  sent  free  upon  application. 

BARRETT.  Dental  Surgery  for  General  Practitioners  and 
Students  of  Medicine  and  Dentistry.  Extraction  of  Teeth, 
etc.     3d  Edition.     Illustrated.  gi.oo 

BROOMELL,  Anatomy  and  Histology  of  the  Human  Mouth 
and  Teeth.  Second  Edition,  Revised  and  Enlarged.  330  Hand- 
some Illustrations.  ^4-5o 

FILLEBROWN.      A    Text-Book    of    Operative     Dentistry. 

Written  by  invitation  of  the  National  Association  of  Dental  Facul- 
ties.    Illustrated.  ^2.25 

QORGAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.    7th  Edition.  Cloth,  ^4.00;  Sheep,  ^5.00 

GORGAS.     Questions  and  Answers  for  the  Dental  Student. 

Embracing  all  the  subjects  in  the  Curriculum  of  the  Dental  Student. 
Octavo.  J6.00 

HARRIS.  Principles  and  Practice  of  Dentistry.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Surgery, 
and  Mechanism.  13th  Edition.  Revised  by  F.  J.  S.  Gorgas,  m.d., 
D.D.s.     1250  Illustrations.  Cloth,  J6.00;  Leather,  J7.00 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art  and 
Practice  of  Dentistry.  6th  Edition.  Revised  and  Enlarged  by  Fer- 
dinand F.  S.  Gorgas,  m.d.,  d.d.s.         Cloth,  ^5.00;  Leather,  J6.00 

RICHARDSON.  Mechanical  Dentistry.  7th  Edition.  Thor- 
oughly Revised  and  Enlarged  by  Dr.  Geo.  W.  Warren.  6gi  Illus- 
trations. Cloth,  J5s. 00;  Leather,  g6.oo 

SMITH.     Dental  Metallurgy.     Illustrated.  $1.75 

TAFT.    Index  of  Dental  Periodical  Literature,  ^2.00 

TOMES.     Dental  Anatomy.    Human  and  Comparative.    263  Illus- 
trations.    5th  Edition.  $4.00 
TOMES.     Dental  Surgery.     4th  Edition.     289  Illustrations.     ^4.00 

^VARP.EN.  Compend  of  Dental  Pathology  and  Dental  Medi- 
cine.    With  a  Chapter  on  Emergencies.     3d  Edition.     Illustrated. 

.80;  Interleaved,  J1.25 

WARREN.  Dental  Prosthesis  and  Metallurgy.  129  Ills.  $1.25 
WHITE.     The  Mouth  and  Teeth.     Illustrated.  .40 


SUBJECT  CATALOGUE. 


DICTIONARIES  AND  CYCLOPEDIAS 

GOULD.  The  Illustrated  Dictionary  ot  Medicine,  Biology 
and  Allied  Sciences,  Being  an  Exhaustive  Lexicon  of  Medicine 
and  those  Sciences  Collateral  to  it:  Biology  (Zoology  and  Botany), 
Chemistry,  Dentistry,  Parniacology,  Microscopy,  etc.,  with  many 
useful  Tables  and  numerous  fine  Illustrations.  1633  pages.  5th  Ed. 
Sheep  or  Half  Morocco,  Jio.oo  ;  with  Thumb  Index,  Jn.oo 
Half  Russia,  Thumb  Index,  ^i2.co 

GOULD.  The  Medical  Student's  Dictionary,  nth  Edition. 
Illustrated.  Including  all  the  Words  and  Phrases  Generally  Used 
inMedicine,  with  their  Proper  Pronunciation  and  Definition,  Based 
on  Recent  Medical  Literature.  With  Table  of  Eponymic  Terms  and 
Tests  and  Tables  of  the  Bacilli,  Micrococci,  Mineral  Springs,  etc., 
of  the  Arteries,  Muscles,  Nerves,  Ganglia,  Plexuses,  etc.  nth  Edi- 
tion, Enlarged  and  illustrated  with  a  large  number  of  Engravings. 
840  pages.  Half  Morocco,  $2.50;  with  Thumb  Index,  $3  00 

GOULD,  The  Pocket  Pronouncing  Medical  Lexicon.  4th  Edi- 
tion. (30,000  Medical  Words  Pronounced  and  Defined.)  Containing 
all  the  Words,  their  Definition  and  Pronunciation,  that  the  Medical, 
Dental,  or  Pharmaceutical  Student  Generally  Comes  in  Contact 
With  ;  also  Elaborate  Tables  of  Eponymic  Terms.  Arteries,  Muscles, 
Nerves,  Bacilli,  etc.,  etc.,  a  Dose  List  in  both  English  and  Metric 
Systems,  etc.,  Arranged  in  a  Most  Convenient  Form  for  Reference  and 
Memorizing.  Fourth  Edition,  Revised  and  Enlarged,  838 
pages.  Full  Limp  Leather,  Gilt  Edges,  Ji.oo  ;  Thumb  Index,  $1.25 
130,000  Copies  of  Gould's  Dictionaries  Have  Been  Sold. 

GOULD  AND  PYLE,  Cyclopedia  of  Practical  Medicine  and 
Surgery.  Seventy-two  Special  Contributors,  Illustrated. 
One  Volume.  A  Concise  Reference  Handbook  of  Medicine, 
Surgery,  Obstetrics,  Materia  Medica,  Therapeutics,  and  the  Various 
Specialties,  with  Particular  Reference  to  Diagnosis  and  Treatment. 
Compiled  under  the  Editorial  Supervision  of  George  M.  Gould, 
M.D.,  Author  of  "  An  Illustrated  Dictionary  of  Medicine,"  etc.; 
and  Walter  L.  Pyle,  m.d..  Assistant  Surgeon  Wills  Eye 
Hospital  ;  formerly  Editor  "  International  Medical  Magazine,"  etc., 
and  Seventy-two  Special  Contributors.  With  many  Illustrations. 
Large  Square  8vo,  to  correspond  with  Gould's  "Illustrated  Dic- 
tionary." Full  Sheep  or  Half  Mor  ,^10.00;  with  Thumb  Index,  $11.00 
Half  Russia,  Thumb  Index,  $12.00  net. 

GOULD  AND  PYLE.  Pocket  Cyclopedia  of  Medicine  and 
Surgery,  Based  upon  above  boolc  and  uniform  in  size  with  "  Gould's 
Pocket  Dictionary." 

Full  Limp  Leather   G'lt  Edges,  81.00,  with  Thumb  Index,  $1.25 

HARRIS,  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art 
and  Practice  of  Dentistry.  6th  Edition.  Revised  and  Enlarged  by 
Ferdinand  J.  S.  GoRGAS,  M.D.,  D.D.s.   Cloth,  J5. 00;  Leather,  $6.00 

LONGLEY,     Pocket  Medical  Dictionary.  Cloth,  .75 

MAXWELL.  Terminologia  Medica  Polyglotta.  By  Dr. 
Theodore  Maxwell,  Assisted  by  Others.  $3.00 

The  object  of  this  work  is  to  assist  the  medical  men  ot  any  nationality 

In   reading   medical  literature  written   in  a  language  not   their  own. 

Each  term  is  usually  given  in  seven  languages,  viz.  :  English,  French, 

German,  Italian,  Spanish,  Russian,  and  Latin. 

TREVES  AND  LANG.    German-English  Medical  Dictionary. 

Half  Calf,  $3.25 


MEDICAL  BOOKS. 


GAR  (see  also  Throat  and  Nose). 

BURNETT.    Hearing  and  How  to  Keep  It.    Illustrated.         .40 

DALBY.      Diseases  and  Injuries  of  the  Ear.    4th  Edition.     38 

Wood  Engravings  and  8  Colored  Plates.  J2.50 

HOVELL.  Diseases  of  the  Ear  and  Naso-Pharynx.  Includ- 
ing Anatomy  and  Physiology  of  the  Organ,  together  with  the  Treat- 
ment of  the  Affections  of  the  Nose  and  Pharynx  which  Conduce  to 
Aural  Disease.     128  Illustrations.     2d  Edition.  ^S-So 

PRITCHARD,  Diseases  of  the  Ear.  3d  Edition,  Enlarged. 
Many  Illustrations  and  Formulae.  $1.50 

ELECTRICITY. 

BIGELCW.  Plain  Talks  on  Medical  Electricity  and  Bat- 
teries. With  a  Therapeutic  Index  and  a  Glossary.  43  Illustra- 
tions.    2d  Edition.  ^i.oo 

HEDLEY.  Therapeutic  Electricity  and  Practical  Muscle 
Testing,     qq  Illustrations.  £2.50 

JACOBY.      Electrotherapy.      2    Vols.    Illustrated.      See    Cohen, 

Physiologic  Therapeutics ,  page  I2. 
JONES.    Medical  Electricity.  3d  Edition.   117  lUus.  ^3.00 

EYE. 

A  Special  Circular  of  Books  on  the  Eye  sent  free  upon  application. 

DONDERS.  The  Nature  and  Consequences  of  Anomalies  of 
Refraction.     With  Portrait  and  Illustrations.     Half  Morocco,  gi. 25 

PICK.  Diseases  of  the  Eye  and  Ophthalmoscopy.  Trans- 
lated by  A.  B.  Hale,  m.  d.  157  Illustrations,  many  of  which  are  in 
colors,  and  a  glossary.  Cloth,  ^4. 50;  Sheep,  ^5. 50 

GOULD  AND  PYLE.  Compend  of  Diseases  of  the  Eye  and 
Refraction.  Including  Treatment  and  Operations,  and  a  Section 
on  Local  Therapeutics.  With  Formulse,  Useful  Tables,  a  Glossary, 
and  III  lUus.,  several  of  which  are  in  colors.     2d  Edition,  Revised. 

Cloth,  .80  ;  Interleaved,  $1.00 

GREEFF.  The  Microscopic  Examination  of  the  Eye.  Illus- 
trated. ^1.25 

HARLAN.    Eyesight,  and  How  to  Care  for  It.    Illus.  .40 

HARTRIDGE.  Refraction.  104  Illustrations  and  Test  Types, 
nth  Edition,  Enlarged.  $1.50 

HARTRIDGE.  On  the  Ophthalmoscope.  4th  Edition.  With 
4  Colored  Plates  and  68  Wood-cuts.  J81.50 

HANSELL  AND  REBER.     Muscular  Anomalies  ot  ihe  Eye. 

Illustrated.  ^1.50 

HANSELL  AND  BELL.  Clinical  Ophthalmology.  Colored 
Plate  of  Normal  Fundus  and  120  Illustrations.  ^1.50 

JENNINGS.  Manual  of  Ophthalmoscopy.  95  Illustrations  and 
I  Colored  Plate.  Ji-So 


10  SUBJECT  CATALOGUE. 

MORTON.     Refraction  of  the  Eye.     Its  Diagnosis  and  the  Cor- 
rection of  its  Errors.     6th  Edition.  ^i.oo 

OHLEMANN.     Ocular  Therapeutics.    Authorized  Translation, 
and  Edited  by  Dr.  Charles  A.  Oliver.  Ji-75 

PARSONS.     Elementary  Ophthalmic  Optics.     With  Diagram- 
matic Illustrations.  fa.oo 

PHILLIPS.     Spectacles  and  Eyeglasses.      Their  Prescription 
and  Adjustment.     2d  Edition.     49  Illustrations.  Ji.oo 

SAVANZY.     Diseases  of  the  Eye  and  Their  Treatment.    7th 

Edition,  Revised  and   Enlarged.     164   Illustrations,  i   Plain    Plate, 
and  a  Zephyr  Test  Card.  J2.50 

From  The  Medical  yews, 

"  Swanzy  has  succeeded  in  producing  the  most  intellectually  con- 
ceived and  thoroughly  executed  resume  of  the  science  within  the 
limits  he  has  assigned  himself.  As  a  'students'  handbook,'  small 
in  size  and  of  moderate  price,  it  can  hardly  be  equaled." 

THORINGTON.    Retinoscopy.    4th  Edition.     Carefully  Revised. 
Illustrated.  |i.oo 

THORINGTON.     Refraction  and  How  to  Refract.    200  Illustra- 
tions, 13  of  which  are  Colored.     2d  Edition.  $1.50 

WALKER.     Students'  Aid  in  Ophthalmology.     Colored  Plate 
and  40  other  Illustrations  and  Glossary.  $i-So 

WRIGHT.    Ophthalmology.     2d  Edition,  Revised  and  Enlarged. 
117  Illustrations  and  a  Glossary.  ^S-oo 


FEVERS. 

GOODALL  AND  W^ASHBOURN.    Fevers  and  Their  Treat- 
ment.    Illustrated.  l3-oo 

HEART. 

THORNE.    The  Schott  Methods  of  the  Treatment  of  Chronic 
Heart  Disease.     Fourth  Edition.     Illustrated.  Nearly  Ready. 


HISTOLOGY. 

GUSHING.  Compend  of  Histology.  By  H.  H.  Gushing,  m.d., 
Demonstrator  of  Histology,  Jefiferson  Medical  College,  Philadelphia. 
Illustrated.    Nearly  Ready .  .80;  Interleaved,  Ji. 00 

STIRLING.  Outlines  of  Practical  Histology.  368  Illustrations. 
2d  Edition,  Revised  and  Enlarged.     With  new  Illustrations.       J2.00 

STOHR.  Histology  and  Microscopical  Anatomy.  Edited  by 
A.  ScHAPER,  M.D.,  University  of  Breslau,  formerly  Demonstrator  of 
Histology,  Harvard  Medical  School.  Fourth  American  from  9th  Ger- 
man Edition,  Revised  and  Enlarged.     379  Illustrations.  Js-oo 


MEDICAL  BOOKS. 


HYGIENE  AND  WATER  ANALYSIS. 

special  Catalogue  of  Books  on  Hygiene  sent  free  upon  application. 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses 
and  Others.  Being  a  Brief  Consideration  of  Asepsis,  Antisepsis,  Dis- 
infection, Bacteriology,  Immunity,  Heating,  Ventilation,  etc.      $1.25 

CONN.     Agricultural  Bacteriology.     Illustrated.  ^2.50 

COPL/IN.  Practical  Hygiene.  A  Complete  American  Text-Book. 
138  Illustrations.     New  Edition.  Preparing . 

HARTSHORNE.     Our  Homes.     Illustrated.  .40 

KEN'WOOD.  Public  Health  Laboratory  Work.  116  Illustra- 
tions and  3  Plates.  I2.00 

LEFFMANN.  Select  Methods  in  Food  Analysis.  53  Illustra- 
tions and  4  Plates.  ^2.50 

LEFFMANN.  Examination  ot  Water  for  Sanitary  and 
Technical  Purposes.     4th  Edition.     Illustrated.  $1-25 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  Illus- 
trated.    Second  Edition.  $1-25 

LINCOLN.     School  and  Industrial  Hygiene.  .40 

McFARLAND.  Prophylaxis  and  Personal  Hygiene.  Care  of 
the  Sick.     See  Cohen.  Physiologic  Therapeutics, page  is. 

NOTTER.  The  Theory  and  Practice  of  Hygiene.  15  Plates 
and  138  other  Illustrations.     8vo.     2d  Edition.  J7.00 

PARKES.  Hygiene  and  Public  Health.  By  Louis  C.  Parkes, 
M.D.     6th  Edition.     Enlarged.     Illustrated.  $3-oo 

PARKES.  Popular  Hygiene.  The  Elements  of  Health.  A  Book 
for  Lay  Readers.     Illustrated.  Ji.zS 

ROSENAU.     Disinfection  and  Disinfectants.     Illustrated. 

Nearly  Ready. 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domestic 
Management  of  the  Ordinary  Emergencies  of  Early  Life,  Massage, 
etc.     6th  Edition.     25  Illustrations.  ^i.oo 

STEVENSON  AND  MURPHY.  A  Treatise  on  Hygiene,  By 
Various   Authors.     In    Three    Octave   Volumes.     Illustrated. 

Vol.  I,  ^6.00;  Vol.  II,  J6.00;  Vol.  Ill,  ^5-00 
*j^  Each  Volume  sold  separately.   Special  Circular  upon  application. 

THRESH.     Water  and  Water  Supplies.     3d  Edition.  ^2.00 

WILSON.    Hand-Book    of  Hygiene  and   Sanitary    Science. 

With  Illustrations.     8th  Edition.  fo.oo 

WEYL.  Sanitary  Relations  of  the  Coal-Tar  Colors.  Author- 
ized Translation  by  Henry  LeFPMANN,  M.D. ,  PH.D.  $1.25 


LUNGS  AND  PLEUR.^. 

KNOPF.      Pulmonary  Tuberculosis.     Its   Modern  Prophylaxis 
and  Treatment  in  Special  Institutions  and  at  Home.     Illus,        $3.00 

STEELL.     Physical  Signs  of  Pulmonary  Disease.   Illus.  J51.25 


SUBJECT  CATALOGUE. 


MASSAGE— PHYSICAL  EXERCISE. 

OSTROM.  Massage  and  the  Original  Swedish  Move- 
ments. Their  Application  to  Various  Diseases  of  the  Body.  A 
Manual  for  Students,  Nurses,  and  Physicians.  Fourth  Edition,  En- 
larged.    105  Illustrations,  many  of  which  are  original.  ^i.oo 

MITCHELL  AND  GULICK.  Mechanotherapy,  Physical 
Education,  etc.  Illustrated.  Sie  Cohen,  Physiologic  Therapeu- 
tics, below. 

TREVES.     Physical  Education.     Its  Value,  Methods,  etc.         .75 

WARD.     Notes  on  Massage.     Interleaved.  Paper  cover,  Ji. 00 


MATERIA    MEDICA    AND     THERA- 
PEUTICS. 

BIDDLE.  Materia  Medica  and  Therapeutics.  Including  Dose 
List,  Dietary  for  the  Sick,  Table  of  Parasites,  and  Memoranda  ot 
New  Remedies.  13th  Edition,  Revised.  64  Illustrations  and  a 
Clinical  Index.  Cloth,  ^4.00;  Sheep,  J5.00 

BRACKEN.    Outlines  of  Materia  Medica  and  Pharmacology.    ^2.75 

COBLENTZ.  The  Newer  Remedies.  Including  their  Synonyms, 
Sources,  Methods  of  Preparation,  Tests,  Solubilities,  Doses,  etc. 
3d  Edition,  Enlarged  and  Revised.  Ji.oo 

COHEN.  Physiologic  Therapeutics.  Methods  other  than  Drug- 
Giving  useful  in  the  Prevention  of  Disease  and  in  the  Treatment  of 
the  Sick.  Mechanotherapy,  Mental  Therapeutics,  Suggestion, 
Electrotherapy.  Climatology,  Hydrotherapy,  Pneumatotherapy, 
Prophylaxis,  Dietetics,  Organotherapy,  Phototherapy,  Mineral 
Waters,  Baths,  etc.  11  Volumes,  Octavo.  Illustrated.  (Subscrip- 
tion.) Cloth,  ^27.50  ;  J^  mor.,g38.5o 
Special  Descriptive  Circular  will  be  sent  upon  application. 

DAVIS.    Materia  Medica  and  Prescription  AVriting.        J1.50 

QORQAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.    7th  Edition,  Revised.  N-oo 

GROFF.  Materia  Medica  for  Nurses,  with  questions  for  Self- Exam- 
ination.    2d  Edition,  Revised  and  Improved.  In  Press. 

HELLER.  Essentials  of  Materia  Medica,  Pharmacy,  and 
Prescription  Writing.  J1.50 

MAYS.    Theine  in  the  Treatment  of  Neuralgia.    %  bound,  .50 

POTTER.  Hand-Book  of  Materia  Medica,  Pharmacy,  and 
Therapeutics,  including  the  Action  of  Medicines,  Special  Therapeu- 
tics, Pharmacology,  etc.,  including  over  600  Prescriptions  and  For- 
mulae. 8th  Edition,  Revised  and  Enlarged.  With  Thumb  Index  in 
each  copy.  Cloth,  J5, 00;  Sheep,  J6.00 

POTTER.  Compend  of  Materia  Medica,  Therapeutics,  and 
Prescription  'Writing,  with  Special  Reference  to  the  Physiologi- 
cal Action  of  Drugs.     6th  Edition.  .80;  Interleaved,  Ji.oo 

MURRAY.     Rough  Notes  on  Remedies.     4th  Edition.  ^1.25 


MEDICAL  BOOKS.  13 


SAYRE.    Organic  Materia  Medica  and  Pharmacognosy.    An 

Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the  Vege- 
table and  Animal  Drugs.  Comprising  the  Botanical  and  Physical 
Characteristics,  Source,  Constituents,  and  Pharmacopeial  Prepara- 
tions, Insects  Injurious  to  Drugs,  and  Pharmacal  Botany.  With 
sections  on  Histology  and  Microtechnique,  by  W.  C.  Stevens. 
374  Illustrations,  many  of  which  are  original,    zd  Edition. 

Cloth,  $4.50 

TAVERA.     Medicinal  Plants  of  the  Philippines.  $1.00 

WHITE  AND  WILCOX.  Materia  Medica,  Pharmacy,  Phar- 
macology, and  Therapeutics.  5th  American  Edition,  Revised  by 
Reynold  W.  Wilcox,  m.a.,  m.d.,  ll.d.,  Professor  of  Clinical 
Medicine  and  Therapeutics  at  the  New  York  Post-Graduate  Medical 
School.  Cloth,  $3.00;  Leather,  $3. so 

"  The  care  with  which  Dr.  Wilcox  has  performed  his  work  is  con- 
spicuous on  every  page,  and  it  is  evident  that  no  recent  drug  possess- 
ing any  merit  has  escaped  his  eye.  We  believe,  on  the  whole,  this  is 
the  best  book  on  Materia  Medica  and  Therapeutics  to  place  in  the 
hands  of  students,  and  the  practitioner  will  find  it  a  most  satisfactory 
work  for  daily  use." —  The  Cleveland  Medical  Gazette. 


MEDICAL    JURISPRUDENCE     AND 
TOXICOLOGY. 

REESE.  Medical  Jurisprudence  and  Toxicology.  A  Text-Book 
for  Medical  and  Legal  Practitioners  and  Students.  5th  Edition. 
Revised  by  Henrt  Leffmann,  m.d.       Clo.,g3.oo;  Leather,  ^3. 50 

"  To  the  student  of  medical  jurisprudence  and  toxicology  it  is  in- 
valuable, as  it  is  concise,  clear,  and  thorough  in  every  respect." — The 
American  Journal  of  the  Medical  Sciences. 

MANN.     Forensic  Medicine  and  Toxicology.     lUus.  J6.50 

TANNER.  Memoranda  of  Poisons.  Their  Antidotes  and  Tests. 
8th  Edition,  by  Dr.  Henry  Leffmann.  .75 


MICROSCOPY. 

CARPENTER.     The  Microscope  and    Its    Revelations.    8th 

Edition,  Revised  and  Enlarged.       817  Illustrations  and  23    Plates. 

Cloth,  $8.00 ;  Half  Morocco,  I9.00 

LEE.  The  Microtomist's  Vade  Mecum.  A  Hand-Book  of 
Methods  of  Microscopical  Anatomy.  887  Articles,  sth  Edition, 
Enlarged.  ^4-oo 

REEVES.  Medical  Microscopy,  including  Chapters  on  Bacteri- 
ology, Neoplasms,  Urinary  Examination,  etc.  Numerous  Illus- 
trations, some  of  which  are  printed  in  colors.  J2.50 

WETHERED.  Medical  Microscopy.  A  Guide  to  the  Use  of  the 
Microscope  in  Practical  Medicine,     too  Illustrations.  J2.00 


SUBJECT  CATALOGUE. 


MISCELLANEOUS. 

BERRY.     Diseases  of  Thyroid  Gland.     Illustrated.  ^4-00 

BURNETT.     Foods  and  Dietaries.     A  Manual  of  Clinical  Diet- 
etics.    2d  Edition.  $1-50 
BUXTON.    Anesthetics.    Illustrated.    3d  Edition.                  $1.50 

COHEN.  Organotherapy.  See  Cohen,  Physiologic  Tlierapeutics 
page  12. 

DAVIS.  Dietotherapy.  Food  in  Health  and  Disease.  With 
Tables  of  Dietaries,  Relative  Value  of  Foods,  etc.  See  Cohen, 
Physiologic  Therapeutics ,  page  I2. 

GOULD.  Borderland  Studies.  Miscellaneous  Addresses  and 
Essays,     lamo.  ^2.00 

GREENE.  Medical  Examination  for  Life  Insurance.  Illus- 
trated.    With  Colored  and  other  Engravings.  J4.00 

HAIG.  Causation  of  Disease  by  Uric  Acid.  The  Pathology  of 
High  Arterial  Tension,  Headache,  Epilepsy,  Gout,  Rheumatism, 
Diabetes,  Bnght's  Disease,  etc.     sthEdition.  $3.00 

HAIG.  Diet  and  Food.  Considered  in  Relation  to  Strength  and 
Power  of  Endurance.     3d  Edition.  $1.00 

HENRY.    A  Practical  Treatise  on  Anemia.  Hall  Cloth,  .50 

LEFFMANN.     Food  Analysis.     Illustrated.  J2.50 

NEW  SYDENHAM  SOCIETY'S  PUBLICATIONS.  Circulars 
upon  application.  Per  Annum,  ^8.00 

OSGOOD.     The  Winter  and  Its  Dangers.  .40 

PACKARD.     Sea  Air  and  Sea  Bathing.  .40 

RICHARDSON.     Long  Life  and  How  to  Reach  It.  .40 

ST.  CLAIR.     Medical  Latin.  Ji.oo 

TISSIER.  Pneumatotherapy.  See  Cohen,  Physiologic  Therapeu- 
tics, page  12. 

TURNBULL.    Artificial  Anesthesia.     4th  Edition.    Illus.    ^2.50 

WEBER  AND  HINSDALE.  Climatology  and  Health 
Resorts.  Including  Mineral  Springs.  2  Vols.  Illustrated  with 
Colored  Maps.     See  Cohen,  Pliysiologic  Therapeutics ,  page  I2. 

WILSON.    The  Summer  and  Its  Diseases.  .40 

WINTERNITZ.  Hydrotherapy,  Thermotherapy,  Photo- 
therapy, Mineral  Waters,  Baths,  etc.  Illustrated.  See  Cohen, 
Pliysiologic  Therapeutics ,  page  12. 


NERVOUS  DISEASES. 

DERCUM.  Rest,  Suggestion,  Mental  Therapeutics.  See 
Co/ten,  PJiysioloiiic  Tlierapeutics, page  12. 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Cen- 
tral Nervous  System.  With  271  original  Colored  and  other 
Illustrations.  Cloth,  $6.00;  Sheep,  J7.00 

GOWERS.    Syphilis  and  the  Nervous  System.  $i.co 


MEDICAL  BOOKS.  15 


GOWERS.    Manual  of  Diseases  of  the  Nervous  System.    A 

Complete  Text-Book.  Revised,  Enlarged,  and  in  many  parts  Re- 
written. With  many  new  Illustrations.  Two  volumes. 
Vol.  I.  Diseases  of  the  Nerves  and  Spinal  Cord.  3d  Edition,  En- 
larged. Cloth,  ^4.00;  Sheep,  jfs.oo 
Vol.  II.  Diseases  of  the  Brain  and  Cranial  Nerves;  General  and 
Functional  Disease.     2d  Edition.              Cloth,  ^4.00;  Sheep,  $5.00 

GOWERS.   Epilepsy  and  Other  Chronic  Convulsive  Diseases. 

2d  Edition.  fe.oo 

HORSLEY.    The  Brain  and  Spinal  Cord.    The  Structure  and 

Functions  of.    Numerous  Illustrations.  $2.50 

ORMEROD.    Diseases  of  the  Nervous  System.    66  Wood  En- 
gravings.  Ji.oo 

PERSHING.      Diagnosis  of  Nervous  and  Mental  Diseases. 

Illustrated.  $i-25 

PRESTON.     Hysteria  and  Certain  Allied  Conditions.    Their 

Nature  and  Treatment.     Illustrated.  J2.00 

WOOD.    Brain 'Work  and  Overwork.  .40 


NURSING  (see  also  Massage). 

special  Catalogue  of  Books  for  Nurses  sent  free  upon  application. 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses  and 
Others.  Being  a  Brief  Consideration  of  Asepsis,  Antisepsis,  Disinfec- 
tion, Bacteriology,  Immunity,  Heating  and  Ventilation,  and  Kindred 
Subjects  for  the  Use  of  Nurses  and  Other  Intelligent  Women.     J1.25 

CUFF.     Lectures  to  Nurses  on  Medicine.    Third  Edition.    $1.25 

DAVIS.  Bandaging.  Its  Principles  and  Practice.  150  Original 
Illustrations.  In  Press. 

DOMVILLE.  Manual  for  Nurses  and  Others  Engaged  in  At- 
tending the  Sick,  gth  Edition.  With  Recipes  for  Sick-room  Cook- 
ery, etc.  In  Press. 

FULLERTON.    Obstetric  Nursing.    41  Ills.    5th  Ed.  Ji.oo 

FULLERTON.     Surgical    Nursing.     3d  Ed.     69  Ills.  ^i.co 

GROFF.  Materia  Medica  for  Nurses.  With  Questions  for  Self-Ex- 
amination.    2d  Edition,  Revised  and  Improved.  hi  Press. 

HADLEY.  General,  Medical,  and  Surgical  Nursing.  A  very 
Complete  iVIanual,  Including  Sick-Room  Cookery.  Just  Ready.  ^1.25 

HUMPHREY.  A  Manual  for  Nurses.  Including  General 
Anatomy  and  Physiology,  Management  of  the  Sick  Room,  etc. 
23d  Edition.     79  Illustrations.  ^i.oo 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domestic  Man- 
agement of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc.  6th 
Edition.    25  Illustrations.  ^i.oo 

TEMPERATURE  AND  CLINICAL  CHARTS.    See  page  6. 

VOSWINKEL.  Surgical  Nursing.  Second  Edition,  Enlarged. 
112  Illustrations.  $1.00 


SUBJECT  CATALOGUE. 


OBSTETRICS. 

CAZEAUX  AND  TARNIER.  Midwifery.  With  Appendix  by 
Mund6.  The  Theory  and  Practice  of  Obstetrics,  including  the  Dis- 
eases of  Pregnancy  and  Parturition,  Obstetrical  Operations,  etc. 
8th  Edition.  Illustrated  by  Colored  and  other  full-page  Plates,  and 
numerous  Wood  Engravings.  Cloth,  J4.50  ;  Full  Leather,  ^5.50 

EDGAR.  Text-Book  of  Obstetrics.  By  J.  Clifton  Edgar. 
M.D.,  Professor  of  Obstetrics,  Medical  Uepartnient  of  Cornell 
University,  New  York  City.     Elaborately  Illustrated.  In  Press. 

FULLERTON.    Obstetric  Nursing.     5th  Ed.    Illustrated,    fi.oo 

LANDIS.  Compend  of  Obstetrics.  7th  Edition,  Revised  by  Wm. 
H.  Wells,  Demonstrator  ot  Clinical  Obstetrics,  Jefferson  Medical 
College.     52  Illustrations.  .80;  Interleaved,  ^i. 00 

WINCKEL.  Text-Book  of  Obstetrics,  Including  the  Pathol- 
ogy and  Therapeutics  of  the  Puerperal  State.    Illus.    fc.oo 


PATHOLOGY. 

BARLOW.     General  Pathology.     795  pages.    Svo.  $5.00 

BLACK.     Micro-Organisms.     The  Formation  of  Poisons.  .75 

BLACKBURN.  Autopsies.  A  Manual  of  Autopsies  Designed  for 
the  Use  of  Hospitals  for  the  Insane  and  other  Public  Institutions. 
Ten  full-page  Plates  and  other  Illustrations.  $i-»S 

CONN.    Agricultural  Bacteriology.     Illustrated.  $2.50 

COPLIN.  Manual  of  Pathology.  Including  Bacteriology,  Technic 
of  Post-Mortems,  Methods  of  Pathologic  Research,  etc.     330  Illus- 
trations, 7  Colored  Plates.     3d  Edition.  $3-50 
DA  COSTA.     Clinical  Hematology.     A  Practical  Guide   to  the 
Examination  of  the  Blood.     Six  Colored  Plates  and  48  Illustrations. 
Just  Ready.                                                       Cloth,  ^5.00  ;  Sheep,  J6.00 
EMERY.    Bacteriological  Diagnosis.     3  Colored  Plates  and  32 
other  Illustrations.    Just  Ready.  ^t-50 
HEWLETT.     Manual  of  Bacteriology.   75  Illustrations.    Second 
Edition,  Revised  and  Enlarged.                                                    In  Press. 
ROBERTS.   Gynecological  Pathology.   Illustrated.                |6.oo 
THAYER.        Connpend    of    General    Pathology.       Illustrated. 
Just  Ready      .80;  Interleaved,  Ji.co 
THAYER.     Compend  of  Special  Pathology.     Illustrated. 

Just  Ready.     .80;  Interleaved,  |i. 00 
VIRCHOW.     Post-Mortem  Examinations.     3d  Edition.  .75 

WHITACRE.  Laboratory  Text-Book  of  Pathology.  With 
121  Illustrations.  $i-50 

WILLIAMS.  Bacteriology.  A  Manual  for  Students.  90  Illus- 
trations.    2d  Edition,  Revised.  Ji-So 

PHARMACY. 

special  Catalogue  of  Books  on  Pharmacy  sent  free  upon  application. 

COBLENTZ.  Manual  of  Pharmacy.  A  Complete  Text-Book 
by  the  Professor  in  the  New  York  College  of  Pharmacy.  2d  Edition, 
Revised  and  Enlarged.   437  Illus.  Cloth,  $3.50;  Sheep,  ^4.50 

COBLENTZ.     Volumetric  Analysis.     Illustrated.  J1.25 


MEDICAL  BOOKS.  17 


BKASLEY.  Book  of  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Most  Eminent  Physicians  and  Surgeons — English, 
French,  and  American.  A  Compendious  History  of  the  Materia 
Medica,  Lists  of  the  Doses  of  all  the  Officinal  and  Established  Pre- 
parations, an  Ij>dex  of  Diseases  and  their  Remedies.     7th  Ed.     J2.00 

BEASLEY.  Druggists'  General  Receipt  Book.  Comprising 
a  Copious  Veterinary  Formulary,  Recipes  in  Patent  and  Proprietary 
Medicines,  Druggists'  Nostrums,  etc. ;  Perfumery  and  Cosmetics, 
Beverages,  Dietetic  Articles  and  Condiments,  Trade  Chemicals, 
Scientific  Processes,  and  many  Useful  Tables.     loth  Ed.  ^2.00 

BEASLEY.  Pharmaceutical  Formulary.  A  Synopsis  of  the 
British,  French,  German,  and  United  States  Pharmacopoeias.  Com- 
prising Standard  and  Approved  Formulse  for  the  Preparations  and 
Compounds  Employed  in  Medicine.     12th  Edition,  $2.00 

PROCTOR.  Practical  Pharmacy.  3d  Edition,  with  Illustrations 
and  Elaborate  Tables  of  Chemical  Solubilities,  etc.  fe.oo 

ROBINSON.     Latin  Grammar  of  Pharmacy  and   Medicine. 

3d  Edition.     With  elaborate  Vocabularies.  $i-75 

SAYRE.    Organic  Materia  Medica  and  Pharmacognosy.    An 

Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the  Vege- 
table and  Animal  Drugs.  Comprising  the  Botanical  and  Physical 
Characteristics,  Source,  Constituents,  and  Pharmacopeial  Prepar- 
ations, Insects  Injurious  to  Drugs,  and  Parmacal  Botany.  With 
sections  on  Histology  and  Microtechnique,  by  W.  C.  Stevens. 
374  Illustrations.     Second  Edition.  Cloth,  $4.50 

SCOVILLE.  The  Art  of  Compounding.  Second  Edition,  Re- 
vised and  Enlarged.  Cloth,  J2.50 

STE'WART.  Compend  of  Pharmacy.  Based  upon  "  Reming- 
ton's Text-Book  of  Pharmacy."  sth  Edition,  Revised  in  Accord- 
ance with  the  U.  S.  Pharmacopoeia,  1890.  Complete  Tables  ot 
Metric  and  English  Weights  and  Measures.     .80;    Interleaved,  ^i. 00 

TAVERA.     Medicinal  Plants  of  the  Philippines.  $2.00 

UNITED  STATES  PHARMACOPCEIA.  7th  Decennial  Revision. 
Cloth,  g2. 50  (postpaid,  ^2. 77) ;  Sheep,  $3.00  (postpaid,  $3.27) ;  Inter- 
leaved, J4.00  (postpaid.  $4.50);  Printed  on  one  side  of  page  only, 
unbound,  fo.50  (postpaid,  $-}.go). 

Select  Tables  from  the  U.  S.  P.     Being  Nine  of  the  Most  Impor- 
tant and  Useful  Tables,  Printed  on  Separate  Sheets.  .25 

POTTER.  Hand-Book  of  Materia  Medica,  Pharmacy,  and 
Therapeutics.    600  Prescriptions.    Sth  Ed.    Clo.,j5.oo;  Sh.,  $6.00 


PHYSIOLOGY. 

BIRCH.  Practical  Physiology.  An  Elementary  Class  Book. 
62  Illustrations.  $1-75 

BRUBAKER.  Compend  of  Physiology.  loth  Edition,  Revised 
and  Enlarged.     Illustrated.  .80;  Interleaved,  gi. 00 

JONES.     Outlines  of  Physiology.     96  Illustrations.  ^1.50 

KIRKES.  Handbook  of  Physiology.  17th  Authorized  Edition. 
Revised,  Rearranged,  and  Enlarged.  By  Prof.  W.  D.  Hallibur- 
ton, of  Kings  College,  London.  681  Illustrations,  some  of  which 
are  in  colors.  Cloth,  $3.00;  Leather,  $3.75 

2 


18  SUBJECT  CATALOGUE. 

LANDOIS.  A  Text-Book  of  Human  Physiology,  Including 
Histology  and  Microscopical  Anatomy,  with  special  Reference  to 
the  Requirements  of  Practical  Medicine.  5th  American,  translated 
from  the  last  German  Edition,  with  Additions  by  Wm.  Stirling, 
M.D.,D.sc.    845  lUus.,  many  of  which  are  printed  in  colors.   In  Press. 

STARLING.     Elements  of  Human  Physiology.     100  Ills.    Ji.oo 

STIRLING.  Outlines  of  Practical  Physiology.  Including 
Chemical  and  Experimental  Physiology,  with  Special  Reference  to 
Practical  Medicine.     3d  Edition.     289  Illustrations.  J2.00 

TYSON.    Cell  Doctrine.     Its  History  and  Present  State.        Ji.so 

PRACTICE. 

BEALE.     On  Slight  Ailments;  their  Nature  and  Treatment. 

2d  Edition,  Enlarged  and  Illustrated.  $i-2S 

FAGGE.  Practice  of  Medicine.  4th  Edition,  by  P.  H.  Pyb- 
Smith.md.     2  Volumes.  Vol,  I,  J6  00;  V o\.\\.  In  Press. 

FOWLER.      Dictionary  of   Practical    Medicine.      By  various 
writers.  An  Encyclopaedia  of  Medicine.  Clo.,$3.oo;  Half  Mor.  J4.00 
GOULD  AND  PYLE.     Cyclopedia  of  Practical  Medicine  and 
Surgery.     A  Concise  Reference  Handbook,  with  particular  Refer- 
ence  to  Diagnosis  and   Treatment.     Edited   by    Drs    Gould    and 
Pyle,  Assisted  by  72  Special  Contributors.     Illustrated,  one  volume. 
Large  Square  Octavo,  Uniform  with  "  Gould's  Illustrated  Diction- 
ary." Sheep  or  Half  Mor.,  $10  00  :  with  Thumb  Index,  $11.00 
Half  Russia,  Thumb  Index,  $12  00 
fl^"  Complete  descriptive  circular  free  upon  application. 
GOULD  AND  PYLE'S  Pocket  Cyclopedia  of  Medicine  and 
Surgery.     Based   upon   the   above   and    Uniform   with   "  Gould's 
Pocket  Dictionary." 

Full  Limp  Leather,  Gilt  Edges,  Round  Corners,  $1.00 
With  Thumb  Index,  J1.25 
HUGHES.    Compend  of  the  Practice  of  Medicine.    6th  Edition, 
Revised  and  Enlarged. 

Part  I.     Continued,  Eruptive,  and  Periodical  Fevers,  Diseases  of  the 
Stomach,   Intestines,   Peritoneum.  Biliary   Passages,  Liver,  Kid- 
neys, etc.,  and  General  Diseases,  etc. 
Part  II.     Diseases  of  the  Respiratory  System,  Circulatory  System, 
and  Nervous  System;  Diseases  of  the  Blood,  etc. 

Price  of  each  part,  .80;  Interleaved,  fi.oo 
Physician's   Edition.     In  one  volume,  including  the  above  two 
parts,  a   Section  on  Skin   Diseases,  and  an  Index.     6th   Revised 
Edition.     625  pp.  Full  Morocco,  Gilt  Edge,  $2.25 

MURRAY.     Rough  Notes  on  Remedies.    4th  Ed.  $1.25 

TAYLOR.     Practice  of  Medicine.    6th  Edition.  l4-oo 

TYSON.  The  Practice  of  Medicine.  By  James  Tyson,  m.d.. 
Professor  of  Medicine  in  the  University  of  Pennsylvania.  A  Com- 
plete Systematic  Text-book  with  Special  Reference  to  Diagnosis  and 
Treatment.  2d  Edition,  Enlarged  and  Revised.  Colored  Plates  and 
125  other  Illustrations.     1222  Pages.       Cloth,  $5.50;   Leather,  $6.50 

STOMACH.     INTESTINES. 

HEMMETER.  Diseases  of  the  Stomach.  Their  Special  Path- 
ology, Diagnosis,  and  Treatment.  With  Sections  on  Anatomy, 
Analysis  of  Stomach  Contents,  Dietetics,  Surgery  of  the  Stomach, 
etc.  2d  Edition,  Thoroughly  Revised  and  in  parts  Rewritten.  With 
Colored  and  other  Illustrations.  Cloth,  $6.00;  Sheep,  f  7.00 


MEDICAL  BOOKS. 


HEMMETER.  Diseases  of  the  Intestines.  Their  Special  Path- 
ology, Diagnosis,  and  Treatment.  With  Sections  on  Anatomy  and 
Phj'siology,  Microscopic  and  Chemic  Examination  of  Intestinal 
Contents,  Secretions,  Feces  and  Urine,  Intestinal  Bacteria  and 
Parasites,  Surgery  of  the  Intestines,  Dietetics,  Diseases  of  the 
Rectum,  etc.  With  Full-page  Colored  Plates  and  many  other 
Original  Illustrations.     2  Volumes.     Octavo.    Just  Ready. 

Price   of  each  Volume,  Cloth,  J5. 00;   Sheep,  56.00 

SKIN. 

BULKLEY.    The  Skin  in  Health  and  Disease.    Illustrated.    .40 
CROCKER.     Diseases  of  the  Skin.     Their  Description,  Pathol- 
ogy, Diagnosis,  and  Treatment,  with  Special  Reference  to  the  Skin 
Eruptions  of  Children.   92  Illus.   3d  Edition.  hi  Press. 

SCHAMBERG.  Diseases  of  the  Skin.  2d  Edition,  Revised  and 
Enlarged.    105  Illustrations.    Being  No.  16  ?  Quiz-Compend?  Series. 

Cloth,  .80;  Interleaved,  |i.oo 

VAN  HARLINGEN.  On  Skin  Diseases.  A  Practical  Manual 
of  Diagnosis  and  Treatment,  with  special  reference  to  Differential 
Diagnosis.  3d  Edition,  Revised  and  Enlarged.  With  Formulae 
and  60  Illustrations,  some  of  which  are  printed  in  colors.        $2-75 

SURGERY  AND  SURGICAL  DIS- 
EASES (see  also  Urinary  Organs). 

BERRY.  Diseases  of  the  Thyroid  Gland  and  Their  Surgical 
Treatment.     Illustrated.  ^4.00 

BUTLIN.  Operative  Surgery  of  Malignant  Disease.  2d  Edi- 
tion.    Illustrated.     Octavo.  $4-50 

DAVIS.  Bandaging.  Its  Principles  and  Practice.  150  Original 
Illustrations.  In  Press. 

DEAVER.  Surgical  Anatomy.  A  Treatise  on  Human  Anatomy 
in  its  Application  to  Medicine  and  Surgery.  With  ahout  400  very 
Handsome  full-page  Illustrations  Engraved  from  Original  Drawings 
made  by  special  Artists  from  Dissections  prepared  for  the  purpose. 
Three  Volumes.     Royal  Square  Octavo. 

Cloth,  ^21.00  ;  Half  Morocco  or  Sheep,  ^24. 00  ;  Half  Russia,  $27.00 
Ccnnplete  descriptive  circular  and  special  terms  upon  application. 

DEAVER.  Appendicitis,  Its  Symptoms,  Diagnosis,  Pathol- 
ogy, Treatment,  and  Complications.  Elaborately  Illustrated 
with  Colored  Plates  and  other  Illustrations.    3d  Edition.   Preparing. 

DULLES.  W^hat  to  Do  First  in  Accidents  and  Poisoning. 
5th  Edition.     New  Illustrations.  $1.00 

FULLERTON.     Surgical  Nursing.    3d  Edition.    69  Illus.    gi.oo 

HAMILTON.     Lectures  on  Tumors.    3d  Edition.  |i-2S 

HEATH.  Minor  Surgery  and  Bandaging.  12th  Edition,  Revised 
and  Enlarged.     195  Illus.,  Formulae,  Diet  List,  etc.  ?i-5o 

HEATiI.  Clinical  Lectures  on  Surgical  Subjects.  Second 
Series.  Nearly  Ready. 

HORWITZ.  Compend  of  Surgery  and  Bandaging,  including 
Minor  Surgery,  Amputations,  Fractures,  Dislocations,  Surgical  Dis- 
eases, etc.,  with  Differential  Diagnosis  and  Treatment.  5th  Edition, 
very  much  Enlarged  and  Rearranged.    167  Illustrations,  98  Formulae. 

Cloth,  .80  ;  Interleaved,  ^i.oo 


20  SUBJECT  CATALOGUE. 

JACOBSON.  Operations  of  Surgery.  4th  Edition,  Enlarged. 
550  Illustrations.     Two  Volumes.  Cloth,  $io.oo;   Leather,  ;Ji2.oo 

KEAY.     Medical  Treatment  of  Gall  Stones.    Just  Ready.  $1.2$ 

KEHR.  Gall-Stone  Disease.  Translated  by  William  Wotkyns 
Skymour,  m  d.  i$2-5o 

MAKINS.  Surgical  Experiences  in  South  Airica.  1899-1900. 
Illustrated.  $4.00 

MAYLARD.  Surgery  of  the  Alimentary  Canal.  97  Illustrations. 
2d  Edition,  Revised.  f3-oo 

MOULLIN.  Text-Book  of  Surgery.  With  Special  Reference  to 
Treatment.  3d  American  Edition.  Revised  and  edited  by  John  B. 
Hamilton,  m.d.,  ll.d..  Professor  of  the  Principles  of  Surgery  and 
Clinical  Surgery,  Rush  Medical  College,  Chicago.  623  Illustrations, 
many  of  which  are  printed  in  colors.     Cloth,  J6. 00;   Leather,  J7. 00 

SMITH.  Abdominal  Surgery.  Being  a  Systematic  Description  ol 
all  the  Principal  Operations.    224  Illus.  6th  Ed.    2  Vols.  Clo.,  $10.00 

VOSWINKEL.  Surgical  Nursing.  Second  Edition,  Revised  and 
Enlarged,     iii  Illustrations.  $1.00 

WALSHAM.  Manual  of  Practical  Surgery.  7th  Ed.,  Re- 
vised and  Enlarged.    483  Engravings.   950  pages.  $3.5° 


TEMPERATURE  CHARTS,  ETC. 

GRIFFITH.  Graphic  Clinical  Chart  for  Recording  Temper- 
ature, Respiration,  Pulse,  Day  of  Disease,  Date,  Age,  Sex, 
Occupation,  Name,  etc.  Printed  in  three  colors.  Sample  copies 
free.  Put  up  in  loose  packages  of  fifty,  .50.  Price  to  Hospitals,  500 
copies,  J4. 00  :   1000  copies,  $7. tio. 

KEEN'S  CLINICAL  CHARTS.  Seven  Outline  Drawings  of  the 
Body,  on  which  may  be  marked  the  Course  of  Disease,  Fractures, 
Operations,  etc.  Each  Drawing  may  be  had  separately,  twenty-five 
to  pad,  25  cents. 

SCHREINER.  Diet  Lists.  Arranged  in  the  form  of  a  chart. 
With  Pamphlets  of  Specimen  Dietaries.     Pads  of  50.  .75 


THROAT   AND    NOSE   (see  also  Ear). 

COHEN.     The  Throat  and  Voice.     Illustrated.  .40 

HALL.  Diseases  of  the  Nose  and  Throat.  2d  Edition,  Enlarged. 
Two  Colored  Plates  and  80  Illustrations.  $2-75 

HOLLOPETER.     Hay  Fever.     Its  Successful  Treatment.      $1.00 

KNIGHT.  Diseases  of  the  Throat.  A  Manual  for  Students. 
Illustrated.  Nearly  Ready. 

LAKE.  Laryngeal  Phthisis,  or  Consumption  of  the  Throat. 
Colored  Illustrations.  $2.00 

McBRIDE.  Diseases  of  the  Throat,  Nose,  and  Ear.  With  col- 
ored Illustrations  from  original  drawings.    3d  Edition.  ?7oo 

POTTER.  Speech  and  its  Defects.  Considered  Physiologically, 
Pathologically,  and  Remedially.  $1.00 

SHEILD.     Nasal  Obstructions.     Illustrated.  $i-5o 


URINE  AND  URINARY  ORGANS. 

ACTON.  The  Functions  and  Disorders  of  the  Reproductive 
Organs  in  Childhood,  Youth,  Adult  Age,  and  Advanced  Life, 
Considered  in  their  Physiological,  Social,  and  Moral  Relations. 
8th  Edition.  ti.75 


MEDICAL  BOOKS.  21 


HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Microscopi- 
cal, for  Laboratory  Use.  Illustrated  and  Interleaved.    6th  Ed.    Ji.oo 

KLEEN.    Diabetes  and  Glycosuria.  J2.50 

MEMMINGER.    Diagnosis  by  the  Urine.   2d  Ed.  24  lUus.   $1.00 

MORRIS.  Renal  Surgery,  with  Special  Reference  to  Stone  in  the 
Kidney  and  Ureter  and  to  the  Surgical  Treatment  of  Calculous 
Anuria.     Illustrated.  J2.00. 

MOULLIN.  Enlargement  of  the  Prostate.  lu  Treatment  and 
Radical  Cure.     2d  Edition.     Illustrated.  ?i-7S 

MOULLIN.  Inflammation  of  the  Bladder  and  Urinary  Fever, 
Octavo.  $1.50 

SCOTT.  The  Urine.  Its  Clinical  and  Microscopical  Examination. 
41  Lithographic  Plates  and  other  Illustrations.    Quarto.  Cloth,  ^5.00 

TYSON.  Guide  to  Examination  of  the  Urine.  For  the  Use  of 
Physicians  and  Students.  With  Colored  Plate  and  Numerous  Illus- 
trations engraved  on  wood.  loth  Edition,  Revised,  Enlarged,  and 
partly  Rewritten.     With  New  Illustrations.  Ji.2S 

VAN   NUYS.    Chemical  Analysis  of  Urine.    39  Illus.         Ji.oo 


VENEREAL  DISEASES. 

GO'WERS.    Syphilis  and  the  Nervous  System.  $1.00 

STURGIS  AND  CABOT.      Student's    Manual    of  Venereal 

Diseases.     7th  Revised  and  Enlarged  Ed.     i2mo.  ^1-25 


VETERINARY. 

B  ALLOU.    Veterinary  Anatomy  and  Physiology.    29  Graphic 
Illustrations.  .80;  Interleaved,  ^i. 00 


WOMEN,  DISEASES  OF. 

BISHOP.     Uterine  Fibromyomata.   Their  Pathology,  Diagnosis, 
and  Treatment.     Illustrated.  Cloth,  $3.50 

BYFORD   (H.   T.).     Manual   of  Gynecology.    Second  Edition, 
Revised  and  Enlarged  by  100  pages.     341  Illustrations.  ^3.00 

DUHRSSEN.     A  Manual    of   Gynecological    Practice.      105 
Illustrations.  $^-5° 

FULLERTON.     Surgical   Nursing,     3d  Edition,   Revised  and 
Enlarged.     69  Illustrations.  $1.00 

LEWERS.    Diseases  of  AVomen.    146  Illus.    5th  Ed.  $2.50 

MONTGOMERY.     Practical    Gynecology,     A  Complete   Sys- 
tematic Text-Book.    527  Illustrations.     Cloth,  $5.00;  Leather,  g6. 00 

ROBERTS.      Gynecological    Pathology.     With   127   Full-page 
Plates  containing  151  Figures.  g6.oo 

WELLS,    Compend  of  Gynecology.    Illustrated.    2d  Edition. 

.80;  Interleaved,  ^i. 00 


SUBJECT  CATALOGUE. 


COMPENDS. 


From  The  Southern  Clinic. 

"  We  know  of  no  series  of  books  issued  by  any  house  that  so  fully 
meets  our  approval  as  these  ?  Quiz-CompendsT.  They  are  well  ar- 
ranged, full,  and  concise,  and  are  really  the  best  line  of  text-books  that 
could  be  found  for  either  student  or  practitioner." 


BLAKISTON'S  ?QUIZ-COMPENDS? 

The  Best  Series  of  manuals  for  tlie  Use  of  Students. 
Price  of  each,  Cloth,  .80.         Interleaved,  for  taking  Notes,  $1.00. 

i^~  These  Compends  are  based  on  the  most  popular  text-books 
and  the  lectures  of  prominent  professors,  and  are  kept  constantly  re- 
vised, so  that  they  may  thoroughly  represent  the  present  state  of  the 
subjects  upon  which  they  treat. 

JS9'  The  authors  have  had  large  experience  as  Quiz-Masters  and 
attaches  of  colleges,  and  are  well  acquainted  with  the  wants  of  students. 

.^~  They  are  arranged  in  the  most  approved  form,  thorough  and 
concise,  containing  nearly  looo  illustrations  and  lithograph  plates, 
inserted  wherever  they  could  be  used  to  advantage. 

i^~  Can  be  used  by  students  of  any  college. 

49~  They  contain  information  nowhere  else  collected  in  such  a 
condensed,  practical  shape.     Circular  free. 

No.  1.  POTTER.  HUMAN  ANATOMY.  Sixth  Revised  and 
Enlarged  Edition.  Including  Visceral  Anatomy.  Can  be  used 
with  either  Morris's  or  Gray's  Anatomy.  117  Illustrations  and  16 
Lithographic  Plates  of  Nerves  and  Arteries,  with  Explanatory 
Tables,  etc.  By  Samuel  O.  L.  Potter,  m.d..  Professor  of  the 
Practice  of  Medicine,  College  of  Physicians  and  Surgeons,  San 
Francisco  ;  Brigade  Surgeon,  U.  S.  Vol. 

No.  2.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  I.  Sixth 
Edition,  Enlarged  and  Improved.  By  Daniel  E.  Hughes,  m.d., 
Physician-in-Chief,  Philadelphia  Hospital,  late  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College,  Phila. 

No.  3.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  II. 
Sixth  Edition,  Revised  and  Improved.     Same  author  as  No.  2. 

No.  4.  BRUBAKER.  PHYSIOLOGY.  Tenth  Edition,  with 
Illustrations  and  a  table  of  Physiological  Constants.  Enlarged 
and  Revised.  By  A.  P.  Bkubaker,  m.d.,  Professor  of  Physiology 
and  General  Pathology  in  the  Pennsylvania  College  of  Dental 
Surgery ;  Adjunct  Professor  of  Physiology,  Jefferson  Medical 
College,  Philadelphia,  etc. 

No.  5.  LANDIS.  OBSTETRICS.  Seventh  Edition.  By  Henry  G. 
Landis,  m.d.  Revised  and  Edited  by  Wm.  H.  Wells,  m.d.. 
Demonstrator  of  Clinical  Obstetrics,  Jefferson  Medical  College, 
Philadelphia.     Enlarged.     52  Illustrations. 

No.  6.  POTTER.  MATERIA  MEDICA,  THERAPEUTICS, 
AND  PRESCRIPTION  WRITING.  Sixth  Revised  Edition 
(U.  S.  P.  1890).  By  Samuel  O.  L.  Potter,  m.d..  Professor  of 
Practice,  College  of  Physicians  and  Surgeons,  San  Francisco; 
Brigade  Surgeon,  U.  S.  Vol. 


MEDICAL  BOOKS. 


?QUIZ-COMPENDS  ?— Continued. 

No.  7,  WELLS.  GYNECOLOGY.  Second  Edition.  ByWM.  H. 
Wells,  m.d.,  Demonstrator  of  Clinical  Obstetrics,  JeflFersoD 
Medical  College,  Philadelphia.     140  Illustrations. 

No.  8.  GOULD  AND  PYLE.  DISEASES  OF  THE  EYE 
AND  REFRACTION.  Second  Edition.  Including  Treatment 
and  Surgery,  and  a  Section  on  Local  Therapeutics.  By  George 
M.  Gould,  m.d.,  and  W.  L.  Pyle,  m.d.  With  Formula,  Glossary 
Tables,  and  109  Illustrations,  several  of  which  are  Colored. 

No.  g.  HORW^ITZ.  SURGERY,  Minor  Surgery,  and  Bandag- 
ing. Fifth  Edition,  Enlarged  and  Improved.  By  Grvillb 
HoRwiTZ,  E.  s.,  M.D.,  Clinical  Professor  of  Genito-Urinary  Surgery 
and  Venereal  Diseases  in  JeflFerson  Medical  College  ;  Surgeon  to 
Philadelphia  Hospital,  etc.   With  98  Formulae  and  71  Illustrations. 

No.  10.  LEFFMANN.      MEDICAL    CHEMISTRY.      Fourth 

Edition.  Including  Urinalysis,  Animal  Chemistry,  Chemistry  ol 
Milk,  Blood,  Tissues,  the  Secretions,  etc.  By  Henry  Leffmann, 
M.D.,  Professor  of  Chemistry  in  the  Woman's  Medical  College  of 
Penna ;  Pathological  Chemist,  Jefferson  Medical  College  Hospital. 
No.  II.  STEWART.  PHARMACY.  Fifth  Edition.  Based  upon 
Prof.  Remington's  Text-Book  of  Pharmacy.  By  F.  E.  Stewart, 
M.D.,  PH.G.,  late  Quiz-Master  in  Pharmacy  and  Chemistry,  Phila- 
delphia College  o£  Pharmacy ;  Lecturer  at  Jefferson  Medical 
College.     Carefully  revised  in  accordance  with  the  new  U.  S.  P. 

No.  12.  BALLOU.  VETERINARY  ANATOMY  AND  PHY- 
SIOLOGY. Illustrated.  By  Wm.  R.  Ballou,  m.d..  Professor 
of  Equine  Anatomy  at  New  York  College  of  Veterinary  Surgeons  ; 
Physician  to  Bellevue  Dispensary,  etc.     29  graphic  Illustrations 

No.  13.  \VARREN.  DENTAL  PATHOLOGY  AND  DEN- 
TAL MEDICINE.  Third  Edition,  Illustrated.  Containing 
a  Section  on  Emergencies.  By  Geo.  W.  Warren,  d.d.s.,  Chiet 
of  Clinical  Staff,  Pennsylvania  College  of  Dental  Surgery. 

No.  14.  HATFIELD.  DISEASES  OF  CHILDREN.  Second 
Edition.  Colored  Plate.  By  Marcus  P.  Hatfield,  Profes- 
sor of  Diseases  of  Children,  Chicago  Medical  College. 

No.  15.  THAYER.   GENERAL  PATHOLOGY.   By  A.  E. 

Thayer,  m.d.,  Cornell  University  Medical  College.     Illustrated. 

No.  16.  SCHAMBERG.  DISEASES  OF  THE  SKIN.  Second 
Edition.  By  Jay  F.  Schameerg,  m.d..  Professor  of  Diseases  of 
the  Skin,  Phib-delphia  Polyclinic.  Second  Edition,  Revised  and 
Enlarged.     105  handsome  Illustrations. 

No.  17.  GUSHING.  HISTOLOGY.  By  H.  H.  Gushing,  m.d.. 
Demonstrator  of  Histology,  Jefferson  Medical  College,  Philadel- 
phia.    Illustrated. 

No.  18.  THAYER.  SPECIAL  PATHOLOGY.  Illustrated.  By 
same  Author  as  No.  15. 

Price,  each,  Cloth,  .80.  Interleaved,  for  taking  Notes,  $1.00. 

Careful  attention  has  been  given  to  the  construction  of  each  sentence, 
and  while  the  books  will  be  found  to  contain  an  immense  amount  of 
knowledge  in  small  space,  they  will  likewise  be  found,  easy  reading ; 
there  is  no  stilted  repetition  of  words  ;  the  style  is  clear,  lucid,  and  dis- 
tinct. The  arrangement  of  subjects  is  systematic  and  thorough  ;  there 
Is  a  reason  for  every  word.    They  contain  over  600  illustrations 


THE  STANDARD  TEXT-BOOK 

MORRIS'  Anatomy 

SECOND  EDITION 

Rewritten.    Revised.    Improved 

WITH  MANY  NEW  ILLUSTRATIONS 


Has  been  recommended  as  a  text-book  at  more  than 
seventy  of  the  most  prominent  medical  schools  in  the  United 
States  and  Canada,  and  is  considered  by  all  anatomists  as  a 
standaid  authority.  It  contains  many  features  of  special 
advantage  to  students.  A  complete  Text-book.  Edited  by 
Henry  Morris,  f.r.c.s.,  Surgeon  to,  and  Lecturer  on 
Anatomy  at,  Middlesex  Hospital,  assisted  by  J.  Bland 
Sutton,  f.r.c.s.,  J.  H.  Davies-Colley,  f.r.c.s.,  Wm.  J. 
Walsham,  f.r.c.s.,  H.  St.  John  Brooks,  m.d.,  R.  Mar- 
cus GuNN,  f.r.c.s.,  Arthur  Hensm.\n,  f.r.c.s.,  Fred- 
erick Treves,  f.r.c.s.,  William  Anderson,  f.r.c.s., 
Prof.  W.  H.  A.  Jacobson,  and  Arthur  Robinson,  m.r.c.s. 

Octavo.    With  790  Illustrations,  of  which  a  large  number 
are  printed  in  colors 

CLOTH,  $6.00;    LEATHER,  $7.00 


"  The  ever-growing  popularity  of  the  book  with  teach- 
ers and  students  is  an  index  of  its  value,  and  it  may  safely 
be  recommended  to  all  interested." — From  The  Medical 
Record,  New  York. 

"Of  all  the  text-books  of  moderate  size  on  human 
anatomy  in  the  English  language,  Morris  is  undoubtedly 
the  most  up-to  date  and  accurate." — From  The  Philadel- 
phia Medical  Journal. 

THUMB  INDEX  IN  EACH  COPY 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RC  418  C38  1902  C.1 


General.pares: 

2002147491 


clinical 


rr   ^  n  1Q88 


